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Full text of "U.S. Navy Medicine Volume 68, Number 3 March 1977"

U.S.NAVY 



March 1977 




VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM Paul Kaufman, MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 

MANAGING EDITOR 

June Wyman 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTRIBUTING EDITORS 

Contributing Editor-in-Chief: 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Carps: CAPT E.E. McDonald 
(DC); Education: CAPT J.S. Cassells 
(MC); Fleet Support: CAPT E.W. Jones 
(MC); Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: LCDR R.E. Broach 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve: CAPT N.V. 
Cooley (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G. M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research: CAPT 
C.E. Brodine (MC); Submarine Medicine: 
CAPT H.E. Glick (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: AH correspondence should be 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: {Area Code 202} 
234-4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316, 
294-4214, Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35), 



U.S.NAVY 




Volume 68, Number 3 
March 1977 



1 From the Surgeon General 

2 Department Rounds 

Toward a quieter Navy . . . Cecil Field going solar . . . Puget Sound's 
big gift . . . Introducing CEARP . . . NRMC Yokosuka nursing 
symposia 

8 Policy Instructions and directives 

10 Notes and Announcements 

New Secretary of Defense . . . Otolaryngology symposium . . . Dental 
continuing education courses . . . Air Force clinical surgeons plan 
April seminar . . . Standard formats developed for medical boards 
, . , Pathology courses set . . . New bed scale developed . . . Neuro- 
logical surgery board examinations . . . Armed Forces obstetricians 
and gynecologists to meet . . . Cardiotachometer introduced . . . 
NRMC Oakland nursing conference held 

12 BUMED SITREP 

13 Scholars' Scuttlebutt 

Restructuring the GME-1 year . . . USUHS on tour 

14 Clinical Notes 

A Short Guide to Bacterial and Viral Infections in Children 
LT R.K. Reed, MC, USNR 

16 Professional 

Child Advocacy at Naval Regional Medical Center Portsmouth, Va. 
CDR T. Lohner, MC, USN 

18 Causes of Hospitalization of Active-Duty Personnel, 1974 
CD R L.J. Melton III, MC, USN 
LP. Hell man, Sc.D. 

21 Independent Duty 

Toothache Diagnosis and Treatment 
LCDR W.S. Hwang, DC, USN 
LT F. Aker, DC, USNR 

23 Roster 

Staff Medical and Dental Officers at Major Activities 

29 NAVMED Newsmakers 

COVER: As part of the Navy Hearing Conservation Program, flightline 
workers are issued specially designed ear muffs that protect them from the 
hazards of aircraft engine noise. To learn more about the Medical De- 
partment's role in hearing conservation, see "Toward a Quieter Navy," 
beginning on page 2. 



NAVMED P-50B8 



From the Surgeon General 



One Anniversary, One Mission 



MARCH 3, 1977, marks the 106th 
anniversary of the establishment of 
the Navy Medical Corps. Rather 
than celebrating this date as the 
birthday of only one corps, I prefer 
that we recognize 3 March as the 
beginning of Navy medicine, and 
the Navy Medical Department as a 
whole. In support of this concept I 
have directed that we abandon the 
tradition of observing individual 
corps birthdays, substituting in- 
stead a unified celebration honoring 
the founding of the Navy Medical 
Department. 

The physicians who participated 
in the creation of the Navy Medical 
Department could never have 
predicted the changes that have 
since occurred in the delivery of 
health services. Standards of care 
and delivery methods are changing 
so rapidly that even today's state of 
the art will be old-fashioned by next 
year's anniversary celebration. 
Never before have we so needed a 
Navy Medical Department that 
works together toward its goal of 
giving excellent service to patients 
entrusted to our care. 



A unified approach to our mission 
and a common anniversary observ- 
ance need not detract from justifi- 
able esprit de corps. But such pride 
of corps can be fully and more ap- 
propriately demonstrated by our 
professional productivity, well- 
groomed appearance, and dedica- 
tion to the Medical Department 
mission. From this time on, our 
commitment should be totally Navy. 
Our Medical Department birthday 
should reflect a continuing, proud 
resolve to go forward united in the 
service of our country. 



M 




W.P. ARENTZEN 

Vice Admiral, MC, USN^" 

Surgeon General of the Navy 




A1 a recent conference, VADM Arentzen greels CAPT Clyde W. 
Jones (MC), chief of the Anesthesiology Service at NRMC San Diego. 



Volume 68, March 1977 




«V 



Circumaural ear protectors muffle noise at target practice; at right, the 
arrow points to a noise dosimeter that measures this man's exposure to 
noise on the flight line. 

Department Rounds 



Preventive Medicine 




Toward a Quieter Navy 



Noise-induced hearing loss is an 
increasingly significant and costly 
problem in the Navy — a problem 
which requires greater command 
attention and emphasis at all levels. 

That was the Secretary of the 
Navy's message to Navy members 
in ALNAV 083/76, issued 10 Dec 
1976. His call to action underscored 
the urgency of the Navy's Hearing 
Conservation Program, and the 
need for all commands to actively 
promote hearing conservation. 

"Hearing impairment to our mili- 
tary and civilian personnel, once in- 
curred, cannot be cured," the Sec- 
retary stressed. "It must be pre- 
vented," Such prevention is the 
focus of current Medical Depart- 
ment efforts in support of the 
Navy's Hearing Conservation Pro- 
gram. 

Setting standards. The Bureau of 
Medicine and Surgery currently 
sets standards for effective hearing 
conservation procedures throughout 



the Navy. The Navy Environmental 
Health Center in Cincinnati, Navy 
preventive medicine units, and the 
Hearing Conservation Service of the 
Naval Aerospace Medical Institute 
in Pensacola work with line com- 
manders and engineering and 
safety workers to develop the best 
possible program. Here is a break- 
down of responsibilities: 

• Line commanders publicize the 
Navy's Hearing Conservation Pro- 
gram, correct hazardous noise lev- 
els, and institute hearing conserva- 
tion measures where noise hazards 
exist. 

• Navy engineers introduce noise 
abatement measures when con- 
structing or modernizing shore fa- 
cilities, and use engineering con- 
trols to reduce noise at its source. 

• Medical Department personnel 
establish and run regional hearing 
conservation programs. Such pro- 
grams include, measuring noise in 
work areas, warning about noise 



hazards, and providing ear protec- 
tors and audiomctric testing. 

In August 1976 the Surgeon Gen- 
eral asked Medical Department fa- 
cilities to review their audiometric 
testing services. To make sure that 
equipment is available throughout 
the region, the Surgeon General 
also directed activities offering 
audiometric services to set up 
regional audiometer pools where 
commands can replace defective or 
uncalibrated audiometers. 

Greatest risk. While some Medi- 
cal Department personnel work to 
prevent hearing loss through audi- 
ometric testing and other measures, 
Navy researchers are trying to pin- 
point ratings in which workers run 
the greatest risk of hearing loss. 
Acoustical scientists at the Naval 
Aerospace Medical Research Labo- 
ratory are studying hearing loss 
among 1,800 enlisted personnel in 
ten ratings where exposure to high 
noise levels is common: airman. 



U.S. Navy Medicine 




lavy mobile hearing conservation van; right, at the Naval Aerospace Medical Research 
aboratory a stall member and test subject evaluate a hearing protective device to deter- 
line its suitability for use by Navy members. 




fireman, aviation boatswain's mate, 
boiler technician, aviation machin- 
ist's mate, machinist's mate, en- 
gineman, aviation structural me- 
chanic, equipment operator, and 
aviation ordnanceman. Tests of the 
hearing sensitivity of personnel in 
these ratings will be compared to a 
control group of 1,800 enlisted 
members in relatively quiet ratings: 
hospital corpsman, dental techni- 
cian, mess management specialist, 
yeoman, personnelman, dispersing 
clerk, training device technician, 
and aviation maintenance adminis- 
trator. The study will be finished in 
mid 1977, according to Ronald M. 
Robertson, Ph.D., principal investi- 
gator. A preliminary finding: the 
hearing of some people in the con- 
trol group is as damaged as the 
hearing of workers exposed to a lot 
of noise. "More ratings are affected 
by noise exposure than we 
thought," Dr. Robertson concludes. 
The Naval Aerospace Medical 
Research Laboratory is not the only 
Navy research facility investigating 
hearing loss. As part of a longitudi- 
nal study of submariners' health, 
scientists at the Naval Submarine 



Medical Research Laboratory, Gro- 
ton, are examining audiograms of 
men who stand watch in submarine 
engine rooms. So far, results have 
paralleled Dr. Robertson's findings: 
people not expected to suffer from 
hearing loss have been affected. 

Researchers at the Groton labora- 
tory also plan to study noise in hy- 
perbaric chambers, where greater- 
than-normal air pressure changes 
the way sound moves, and affects 
the ear's efficiency. "It looks as if 
there's a loss of sensitivity to sound 
as you subject the ear to greater 
pressure," says Paul Smith, a psy- 
chologist working on the study. 
Divers have reported sudden hear- 
ing losses after completing a dive; 
by exploring hyperbaric chamber 
noises, such as the sounds made by 
ventilating equipment, scientists at 
the Groton laboratory hope to find 
out why. 

Ear protectors. In the Navy, three 
types of ear protectors — ear plugs 
worn in the ear canal, ear caps 
which occlude the ear canal open- 
ing, and ear muffs which cover the 
entire ear — are issued to people 
who work with noisy machinery. 



Some Navy workers require highly 
specialized protection: for example, 
crewmembers who work on carrier 
flight decks need a telephone head- 
set that protects their hearing while 
enabling them to understand direc- 
tions given over the telephone. 
Navy acoustical scientists in Pensa- 
cola worked with the Naval Air En- 
gineering Center to devise a new 
sound-powered telephone which re- 
duces the amount of noise that 
reaches the ear while clearly repro- 
ducing speech. Model units are now 
being tested aboard the USS John 
F. Kennedy and USS Nimiiz. 

Another recent advance in ear 
protection is a comfortable, light- 
weight ear protector developed at 
the Naval Undersea Center in San 
Diego. Originally designed for sub- 
marine personnel to wear during 
sonar operations, the three-ounce 
ear muff consists of two foam ear 
covers held in place by a nylon mesh 
helmet. 

But ear protectors are useless if 
workers won't wear them. Many 
engine-room workers complain that 
when they wear ear protectors they 
cannot hear subtle engine noises 



Volume 68, March 1977 



which indicate machinery malfunc- 
tion. "When a main bearing in an 
engine starts to go, it makes a very 
distinctive noise," explains Paul 
Smith. "But some men complain 
that with the ear muffs they can't 
hear these noises." To find out 
whether there is any truth in this 
claim, Mr. Smith and his colleagues 
are testing the hearing of Navy 
workers who wear ear muffs. While 
preliminary results indicate that the 
muffs do not interfere with a per- 
son's ability to detect changes in 
pitch and intensity, it is still not 
known whether ear muffs prevent 
the wearer from discriminating be- 
tween finer differences in sound. 

Field programs. Medical Depart- 
ment personnel are also working to 



improve hearing conservation pro- 
grams in the field. Among the most 
promising ideas is a mobile hearing 
conservation trailer. With this trail- 
er, audiometric technicians at Naval 
Regional Medical Center Charles- 
ton, S.C., visit ships in port and 
naval shore facilities to test the 
hearing of Navy members and outfit 
them with ear protectors. 

When conducting environmental 
health surveys, teams of Navy in- 
dustrial hygienists routinely look for 
indicators of a good hearing conser- 
vation program. Some sure signs: 
• trained audiometric technicians.* 



*The Hearing Conservation Service, Naval 
Aerospace Medical Institute, trains a!! Navy 
audiometric technicians. 



• proper audiometric testing and 
record-keeping. 

• analyses of noise in work areas. 

• properly calibrated audiometric 
testing equipment. 

• follow-up of people whose hear- 
ing is shown in audiograms to be 
impaired. 

Follow-up is the crucial step, ac- 
cording to CAPT Thomas Markham 
(MC), commanding officer of the 
Navy Environmental Health Center. 
Says CAPT Markham: "People who 
are hard of hearing should be eval- 
uated by a physician to determine 
the cause of their hearing loss. Not 
all hearing loss is induced by 
noise," he warns. "It may be 
caused by disease, trauma, drugs, 
or a tumor, and may be treatable." 




Cecil Field Going Solar 

The first solar energy system in any Navy medical 
facility will be installed sometime this summer to pro- 
vide hot water at the new Naval Medical and Dental 
Clinic, Cecil Field, Fla. The system of solar collectors, 
water pumps and tanks should be operating by fall, 
with the clinic's existing heating system serving as a 
back-up source of heat on cloudy days. 



Proposed solar energy system at Cecil Field 



The $2.2 million Cecil Field clinic, dedicated last 
December, includes a pharmacy, laboratory, X-ray and 
physical therapy facilities, administrative offices, and 
examining rooms for military sick call and outpatient 
treatment. The dental clinic area has five dental opera- 
tories, four oral hygiene treatment stations, and a pros- 
thetic laboratory. 



4 



U.S. Navy Medicine 



NNMC 



Puget Sound's Big Gift 



Steven Nix is a hemophiliac. 
Twenty years ago this young Navy 
dependent would have been forced 
to lead a sedentary life, fearing that 
the slightest injury could trigger an 
episode of intense bleeding. 

Today, with dramatic technologi- 
cal advances in the field of blood 
banking, and supported by the re- 
sources of the Navy Blood Program, 
Steven can enjoy a normal life. 

Last June, Steven was the in- 
spiration behind a massive blood 
drive aboard the USS Puget Sound, 
where his father, CDR H.W. Nix, 
Jr., SC, USN, is supply officer. CDR 
Nix's involvement in his son's medi- 
cal treatment had made him aware 
of the services offered by the Navy 
Blood Program, and of the pro- 
gram's constant need for donated 
blood. So while Steven was under 
the care of physicians at the 
National Naval Medical Center 
(NNMC) in Bethesda, Md., CDR 
Nix discussed with LT Patrick 
Monahan (MSC), head of the 
NNMC Blood Bank, the idea of a 
large-scale volunteer drive aboard 
the Puget Sound. The idea later won 
the support of the Puget Sound's 
commanding officer, CAPT Charles 
Home III, who encouraged the crew 
to participate. 

To accommodate such a large 
donation of blood — from which 
units can be freely fractionated into 
components— NNMC Blood Bank 
technicians transported two 600-lb. 
refrigerated centrifuges by truck to 
the Puget Sound helicopter hangar 
bay. The rest of the equipment was 
flown from the Naval Air Facility at 
Andrews Air Force Base to Norfolk, 
Va., where the Puget Sound was 
docked. 

Puget Sound crewmembers 
hoisted the bulky equipment 
aboard, working so carefully that 
the delicate centrifuges did not re- 
quire recalibration after the trans- 
fer. The crew also took care of the 




NNMC blood bank technicians head for 
the Puget Sound where, below, they 
undertake a large-scale blood procure- 
ment effort. 



special electrical hookup required 
for the complex blood processing 
equipment. 

Components. Once the equip- 
ment was installed, technicians 
from the NNMC Blood Donor Cen- 
ter, assisted by corpsmen from 
Naval Regional Medical Center 
Portsmouth, Va., began drawing 
blood. Federal Drug Administration 
standards require that whole blood 
which is to be fractionated must be 
separated within four hours of the 
time it is donated, and blood plasma 
must be frozen within six hours of 
donation. Aboard the Puget Sound, 
screening, procurement and proc- 
essing of the donated blood was 
accomplished within two hours. The 
blood components were then flown 
to NNMC where further blood 
group typing and processing was 
done. Because the shelf -life of 
several blood components is rela- 
tively short, NNMC Blood Bank 
personnel worked into the early 
hours of the morning to complete 
the job. 

With the technological advances 
made over the past decade in sepa- 
rating blood into its many compo- 
nents — plasma, red cells, white 
cells, platelets, proteins, albumin, 
clotting factors and cryoprecipitates 




Volume 68, March 1977 



— three to five patients can now 
benefit from each unit of donated 
whole blood. For example, red 
blood cells, which can be isolated 
and preserved in a refrigerated 
state for only 21 days, are screened 
at the NNMC Blood Bank and then 
used to treat anemic patients, or in 
emergency room, surgical, or trans- 
plantation procedures. Blood plate- 
lets can only be preserved for 72 
hours; they are processed and used 




primarily to treat leukemia victims. 
The other blood components are 
similarly typed and used in many 
phases of medical care. 

The discovery that changed the 
life of hemophiliacs like Steven Nix 
was the identification and isolation 
of a particular blood clotting factor 
known as cryoprecipitate, or Factor 
VIII — the only blood constituent 
lacking in victims afflicted with 
classic hemophilia. By separating 
whole blood into its components and 
then subjecting the plasma to 
quick-freezing at -82° Centigrade in 
a cryoprecipitate bath of alcohol and 
dry ice, technicians can isolate this 
important component. 

Formerly, victims of hemophilia 
were subject to bleeding crises 
which required massive transfu- 
sions of whole blood. With the use 
of Factor VIII in prophylactic ther- 
apy, however, they need only ad- 
minister an injection once every 48 
hours to ensure that enough Factor 
VIII is in their bloodstream to en- 
able blood to clot properly. 

While processing blood plasma to 
isolate Factor VIII has become in- 



HN Elton Mosher, left, labels a unit of 
donated blood; below, HN Linda Navar- 
ro assists the Puget Sound CO, who 
donated one of 435 units collected in the 
drive. 




^ I 



creasingly popular as an economical 
and relatively simple treatment of 
hemophilia, researchers are also 
investigating the possibility of ob- 
taining Factor VIII by chemical frac- 
tionalization, glycine precipitation, 
or even synthetic production. How- 
ever, these procedures are still ex- 
perimental and quite costly. 

Cooperative effort. Distribution 
of donated whole blood and blood 
components within the Navy is co- 
ordinated through the Blood Pro- 
gram Management Branch of the 
Bureau of Medicine and Surgery. 
This branch oversees the operation 
of what is believed to be the world's 
largest regional blood program. 
Through this Navywide cooperative 
effort, many Navy medical facilities 
benefit from large donation projects 
such as that sponsored by the Puget 
Sound. 

Of the 435 units of blood donated 
by Puget Sound crewmembers, 145 
units were collected and used by 
NRMC Portsmouth. The remainder 
went to the NNMC Blood Bank for 
further separation and processing, 
and were then sent to other naval 
hospitals in the region. 

The large volunteer donation also 
enabled NNMC to meet urgent 
needs of other armed forces medical 
centers. For an emergency at the 
Walter Reed Army Medical Center, 
for example, NNMC was able to 
provide 30 units of A-positive blood. 
With the assistance of the Blood 
Program Management Branch, 100 
units of blood plasma were provided 
to the Burn Treatment Center at 
Brooke Army Medical Center in 
Houston. Another 35 units of blood 
components went to Malcolm Grow 
U.S. Air Force Medical Center at 
Andrews Air Force Base, Md. The 
NNMC Blood Bank also cooperates 
with local civilian hospitals to ex- 
change blood in emergencies. 

While the men of the Puget 
Sound volunteered their blood to 
help the son of a crewmember, their 
donations — and those of other Navy 
men and women — are invaluable in 
treating thousands of people 
throughout the Navy each year. 
— PAO. National Naval Medical Center. 



U.S. Navy Medicine 



Nurse Corps 

Introducing 
CEARP 

The Medical Department is de- 
veloping programs of continuing 
education for Navy nurses that will 
meet American Nurses' Association 
(ANA) national standards for ac- 
creditation. 

BUMED Instruction 1520.23 of 22 
Nov 1976 establishes the Continuing 
Education Approval and Recogni- 
tion Program (CEARP) for the Navy 
Nurse Corps. The program will give 
commanding officers a way to gain 
national recognition for Nurse Corps 
continuing education programs de- 
veloped in their facilities. 

The new program was prompted 
by growing awareness in the 
nursing profession of the need to 
maintain competence, and by action 
in state legislatures to make contin- 
uing education a condition for reli- 
censure. 

The CEARP will assure the 
quality of Navy-sponsored continu- 
ing education offerings for nurses, 
enabling Navy nurses to accrue 
credit toward relicensure in their 
home state by participating in pro- 
grams that meet national standards. 
The ANA has set standards for 
continuing nursing education by 
establishing a national system of 
accreditation. Accreditation serves 
two purposes: It establishes that the 
educational programs of the ac- 
credited organization need no fur- 
ther review to award credit to par- 
ticipants; and it gives the accredited 
organization authority to approve 
continuing education offerings of its 
constituent activities so that they, in 
turn, may award credit for partici- 
pation. 

The Navy Nurse Corps will seek 
accreditation of its continuing edu- 
cation approval process as soon as 
the CEARP is functioning. In the 
Medical Department, the Naval 
Health Sciences Education and 
Training Command (HSETC) will be 
the recognized approval body once 



CDR Lois Ewalt (NC) leads symposium 



ANA accreditation has been ob- 
tained. HSETC will keep records of 
each Nurse Corps officer's continu- 
ing education accomplishments, 
and of approved programs offered 
at Navy medical facilities. A Nurse 
Corps CEARP review board will 
meet quarterly to review applica- 
tions for approval of programs. 

The Navy Nurse Corps Continu- 
ing Education Approval and Recog- 
nition Program Manual gives guide- 
lines for planning and implement- 
ing continuing education programs 
and submitting them for approval, 
and describes the criteria on which 
approval is based. Continuing edu- 
cation programs for nurses may in- 
clude: 

• short courses and short-term staff 
development. 

• presentations at or participation 
in health-related professional meet- 
ings, courses, or workshops. 

• publication of papers, books, and 



manuals, and development of au- 
diovisual materials. 

• independent or informal study. 

• formal academic study. (To ob- 
tain recognition for formal academic 
study, Nurse Corps officers should 
submit transcripts of their grades 
directly to their state board of 
nursing.) 

Applications for approval of con- 
tinuing nursing education programs 
or offerings may be forwarded to 
the Commanding Officer, Naval 
Health Sciences Education and 
Training Command, Code 7, follow- 
ing procedures set forth in the 
CEARP Manual. Questions about 
CEARP may be addressed to the 
Director, Nurse Corps Programs, 
Naval Health Sciences Education 
and Training Command (Code 7), 
National Naval Medical Center, 
Bethesda, Md. 20014; or phone 
(Area code 202) 295-0630, (Auto- 
von) 295-0630. 



Nursing Symposia at 
NRMC Yokosuka 

As more states move to require continuing education credits for re- 
licensure of nurses, Navy medical facilities are expanding their con- 
tinuing education programs to meet those requirements. U.S. Naval 
Regional Medical Center, Yokosuka joined the trend with a series of 
symposia that are reaching not only Navy nurses but Army, Air 
Force, and even civilian American nurses in Japan. 

When CDR Ellen Graves (NC), chief of the medical center's 
nursing service, first planned the symposia, her idea was to help 
Navy nurses by augmenting the medical center's in-service nursing 
education program. But before long other American nurses in the 
area asked to attend. For civilian nurses, many of whom are depend- 
ents of military personnel stationed in Japan, this is their only chance 
to attend formal continuing education courses. 

At the first symposium, presentations covered counseling tech- 
niques, listening as a factor in communication, legal aspects of ward 
management, and the charge nurse's role in staff development. A 
second symposium dealt with physical and psychological signs of 
cultural maladjustment. On the drawing board are plans for a tri- 
service continuing education project to feature health care experts 
from the Navy, Army and Air Force. 




Policy 



Instructions and 
Directives 

Exposure to lead in indoor firing ranges 

Staff members of indoor firing ranges risk inhaling 
excessive airborne inorganic lead. An industrial hy- 
giene officer shall evaluate the ventilation, monitoring 
of airborne lead, and housekeeping at indoor firing 
ranges at least once yearly. Air samples from the work- 
ers' breathing zone shall be analyzed for inorganic lead 
twice a year. Workers shall never be exposed to con- 
centrations of lead greater than 0.15 mg per cubic 
meter of air, determined as a time-weighted average 
exposure for an eight-hour day. 

Personnel who work in indoor firing ranges shall 
have annual medical examinations. Urinary lead levels 
shall be determined every six months, or blood lead 
levels once a year; when levels equal or exceed 0.08 mg 
Pb per 100 g in the blood, or 0.20 mg Pb per liter in the 
urine, calculated to a specific gravity of 1.024, exposure 
to lead shall be reduced. 

Installation commanders shall keep records of indus- 
trial hygiene survey and sampling results, and budget 
or allocate funds to support the indoor firing range lead 
hazard control program. 

Indoor firing range personnel shall follow protective 
measures outlined in enclosure (1). Technical assist- 
ance is available from industrial hygiene services iden- 
tified in enclosure (2). — BUMED Instruction 6270.5A of 
23 June 1976. 

Armed Forces nutritional standards 

This tri-service instruction defines the responsibili- 
ties of the Navy, Army, and Air Force Surgeons Gener- 
al in ensuring adequate nutrition for their personnel. 
The Surgeons General shall: 

• establish appropriate nutritional and dietary stand- 
ards for all personnel. 

• guide commanding officers in determining ideal body 
weights and methods of achieving these weights. 

• provide qualified representatives to work with food 
procurement and food service personnel, recommend 
adjustments in dietary standards for different physical 
statuses and environmental conditions, and assist in 
nutrition education programs. 

• survey the nutritional adequacy of the Armed Ser- 
vices diet and recommend changes in this diet, as 
needed. 

• consider requests to deviate from established nutri- 
tional standards. 



• supervise studies to determine the nutritional status 
of personnel. 

A table of the recommended nutrient allowances for 
military personnel, with a discussion of some of the 
nutrients, is provided in this instruction. Factors which 
affect caloric requirements are also covered. — BUMED 
Instruction 10110.3E of 30 Aug 1976. 

Cold injury 

"Cold Injury," a chapter in the Medical Depart- 
ment's Technical Information Manual for Medical 
Corps Officers, has been revised. Topics covered in the 
new version include: 

• Types of cold injuries and their causes. 

• Preventive measures, such as protective clothing and 
analysis of meteorological data. 

• Pathogenic mechanisms contributing to tissue loss 
from cold injury. 

• First aid, emergency medical treatment in forward 
areas, and definitive hospital treatment for cold in- 
juries. 

• Causes, clinical signs and treatment of hypothermia. 

• Sensitiveness of people with cold injuries to further 
exposure. 

• Effective temperatures for the combined effect of 
various wind speeds and air temperatures. 

Copies may be ordered from the Naval Publications 
and Forms Center, 5801 Tabor Ave., Philadelphia, Pa. 
19120. Ask for NAVMED P-5052-29 of 30 Sept 1976. 

Dental facility inspections 

This instruction provides a tentative schedule, 
through September 1977, of inspections of BUMED- 
commanded dental activities, and professional/techni- 
cal visits to dental departments of non-BUMED-com- 
manded activities. The Inspector General, Dental will 
give activities specific inspection dates approximately 
two months before the visit. Inspections of naval 
regional dental centers will include inspections of all 
branch dental clinics under the regional center's com- 
mand.— BUMED Notice 5040 of 13 Oct 1976. 

Enlisted Adviser Program 

To provide guidance for enlisted personnel in grades 
E-l through E-6, commanding officers shall establish 
an Enlisted Adviser Program. Chief petty officers shall 
be designated enlisted advisers, although first class 
petty officers may be designated when no chief petty 
officer is available. Master chief petty officers and 
career counselors shall assist enlisted advisers. 

As part of this program, enlisted advisers may: 

• Meet regularly with junior enlisted personnel to 
explain command policy and actions. 

• Promote the advantages of a Navy career. 

• Ensure that superior performance is recognized and 
rewarded. 



U.S. Navy Medicine 



• Counsel enlisted members involved in disciplinary 
problems, and accompany them to mast. 

• Inform enlisted members of training requirements 
and new training programs. 

• Help enlisted members prepare for advancement in 
rate examinations. 

• Provide counsel on personal and financial problems. 

• Solicit suggestions on improving patient care and 
hospital procedures, and forward these suggestions to 
appropriate officials.— BUMED Instruction 5390.1 of 9 
Nov 1976. 

Dental profiles 

The Bureau of Medicine and Surgery uses an auto- 
matic data processing system to produce profiles of the 
productivity of each Navy dental facility. Dental profiles 
are composed of three major statistical measurements: 
"percent effectiveness" of a dental activity; number of 
sittings per dental officer; and the ratio of the staffs 
available work time to the time staff members actually 
worked. Commanding officers should use these profiles 
to assess the efficiency of dental care. — BUMED Notice 
6620 of 10 Nov 1976. 

Yellow fever immunization 

To effectively administer required yellow fever 
vaccine to prospective Alert Forces personnel, com- 
mands shall ensure that Navy and Marine Corps en- 
listed men receive such vaccine immunizations during 
the final week of their recruit training, unless vaccina- 
tion is medically contraindicated. Male students of the 
Marine Corps Basic School, the Naval Academy, and 
the Naval Education and Training Center shall be 
immunized against yellow fever (unless medically con- 
traindicated) during their final week of school. Since 
women seldom serve with the Alert Forces, they should 
be immunized only as needed.— BUMED Notice 6230 
of 18 Nov 1976. 

Aviation selection tests 

The U.S. Navy and Marine Corps aviation selection 
test is used to select Navy, Marine and Coast Guard 
students for naval aviator, naval flight officer and air 
intelligence training. The academic qualification and 
mechanical comprehension sections of the test are also 
used as an officer aptitude rating test to select students 
for non-aviation officer training programs. 

Instructions for administering and scoring these tests 
are given in NAVMED P-5098 ("Examiner's Manual 
and Scoring Instructions for the U.S. Navy and Marine 
Corps Aviation Selections Tests"). Page 7 of that 
manual gives special instructions for testing Officer 
Candidate School applicants who want to be considered 
for aviation programs. Qualifying scores for the officer 
aptitude rating test are established and promulgated by 
the Navy Recruiting Command and Marine Corps 
Headquarters. 



Scoring keys and test booklets are designated "For 
Official Use Only"; they must be counted before and 
after each test session, and locked up when not in 
use.— BUMED Instruction 1532. 1H of 18 Nov 1976. 

Influenza immunization program 

This notice discusses currently prevalent influenza 
strains, and required composition of vaccines and im- 
munization procedures for 1976-1977. A schedule of 
dosages for active-duty Navy personnel and Navy 
health care beneficiaries is furnished, and procedures 
are described for obtaining the consent of non-active- 
duty patients before they are immunized. — BUMED 
Notice 6230 of 20 Oct 1976. [ Note: The Navy's Influen- 
za Immunization Program is currently suspended in- 
definitely, pending evaluation of potential neurologic 
complications. — Ed.] 

Blood typing sera 

The Naval Supply Manual, paragraph 22002, re- 
quires Navy activities to procure blood typing sera from 
standard Navy stock items instead of on the open 
market. This regulation sometimes makes it impossible 
to satisfy Food and Drug Administration requirements 
that two different sera be used in each blood typing 
action. To satisfy the FDA requirement, Medical De- 
partment activities that operate blook banks are 
authorized to purchase blood typing sera on the open 
market, or to use Navy stock sera. — BUMED Instruc- 
tion 6530. 12A of 29 Oct 1976. 

Releasing information from medical records 

Department of Defense policy allows qualified medi- 
cal researchers access to medical records of military 
personnel. Researchers' requests for medical records 
will be forwarded for approval to the Special Assistant 
to the Surgeon General for Medical Research and De- 
velopment (BUMED Code 0012). Requests shall 
include the research design and a statement that: 

• the privacy of the records will be maintained. 

• cases will not be identified by name. 

• research results will not be published without BU- 
MED approval. 

If these criteria are met, the requested information 
may be released subject to provisions of the Privacy Act 
of 1974.— BUMED Instruction (internal) 6150. 14G of 19 
Nov 1976. 

Report of civilian employment 

BUMED-commanded activities are required to sub- 
mit to BUMED Code 37 a copy of civilian employment 
reports they prepare each month for the Office of the 
Comptroller of the Navy. These NAVSO 7410/1 reports 
are required no later than the 20th of the month after 
the reported month.— BUMED Instruction 7410.1 of 8 
Dec 1976. 



Volume 68, March 1977 



Notes & Announcements 



DR. HAROLD BROWN IS NEW 
SECRETARY OF DEFENSE 

Harold Brown, Ph.D., a former Secretary of the Air 
Force who has been president of the California Institute 
of Technology since 1969, has been named Secretary of 
Defense. His appointment was confirmed by the U.S. 
Senate on 21 January. 

Dr. Brown, who earned a Ph.D. in physics at Colum- 
bia University, has held many teaching and research 
positions and was director of the E.O. Lawrence Radia- 
tion Laboratory, Livermore, Calif. He has served as a 
science adviser on the Polaris Steering Committee, the 
Air Force Scientific Advisory Board and the President's 
Science Advisory Board; was senior science adviser at 
the Conference on the Discontinuance of Nuclear Tests 
(1958-1959); and was a delegate to strategic arms limi- 
tation talks in Helsinki, Vienna and Geneva. 

Dr. Brown was director of defense research and engi- 
neering for the Department of Defense from 1961 until 
1965, when he was named Secretary of the Air Force. 
He became head of the California Institute of Technol- 
ogy in 1969. 




Harold Brown, Ph.D. 

NNMC TO SPONSOR OTOLARYNGOLOGY 
SYMPOSIUM 

A symposium on "Current Therapy for Malignancy 
of the Oral Cavity and Related Structures" will be held 
2-4 June 1977 at the National Naval Medical Center. 
For details, write to CDR Alan D. Kornblut, MC, 
USNR, Department of Otolaryngology, National Naval 
Medical Center, Bethesda, Md. 20014. 



DENTAL CONTINUING EDUCATION 
COURSES OFFERED IN MAY 

These dental continuing education courses will be 
offered in May 1977: 

National Naval Dental Center, Bethesda, Md. 
Management seminar (limited to 
dental officers assigned to 
the course by BUMED) 9-13 May 1977 



Eleventh Naval District, San Diego, Calif. 



Periodontics 



9-11 May 1977 



Letterman Army Medical Center, San Francisco, Calif. 
Oral surgery 2-5 May 1977 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. Applications for other dental continuing 
education courses should be submitted to: Command- 
ing Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should 
arrive six weeks before the course begins. 

Cross-country travel and travel from outside the con- 
tinental U.S. generally will not be approved due to 
funding limitations. 

AIR FORCE CLINICAL SURGEONS 
PLAN APRIL SEMINAR 

The Society of Air Force Clinical Surgeons will offer a 
postgraduate surgical seminar 17-20 April 1977 at the 
San Antonio (Tex.) Convention Center. Participants will 
receive Category I continuing education credit. For 
more information, contact COL Thomas P. Ball, Jr., 
Program Chairman, Society of Air Force Clinical Sur- 
geons, Wilford Hall USAF Medical Center (SGHSE), 
Lackland Air Force Base, Tex. 78236. 

STANDARD FORMATS DEVELOPED 
FOR MEDICAL BOARDS 

Standardized formats for dictating medical board re- 
ports on ischemic heart disease and cardiac catheteriza- 
tion patients have been developed at Naval Regional 
Medical Center San Diego. Prepared paragraphs are 
stored in a data bank in the medical center's central 
transcription pool; when dictating the results of a medi- 
cal board, the physician provides only pertinent infor- 
mation on the patient, instead of creating a report from 
scratch. The standard formats are available from CDR 
W.V.R. Vieweg, MC, USN, Director, Cardiac Catheter- 
ization Laboratory, Naval Regional Medical Center, San 
Diego, Calif. 92134. 



10 



U.S. Navy Medicine 



PATHOLOGY COURSES SET FOR MAY 

The Armed Forces Institute of Pathology (AFIP) an- 
nounces the following courses to be held in Washing- 
ton, D.C.: 

• Hematopathology, 4-6 May 1977: a refresher course 
covering current trends in diagnostic hematologic pa- 
thology, particularly morphology. 

• Comparative pathology, 9-11 May 1977: deals with 
disease processes found in both animals and man; 
pathologic lesions and biological behavior of disease 
organisms in animals and man will be compared. 

Although the courses are designed primarily for 
military and federally employed scientists and health 
care professionals, civilians will be admitted if space is 
available. To obtain applications, write to the Director, 
Armed Forces Institute of Pathology, ATTN: AFIP- 
EDE, Washington, D.C, 20306. 

NEW BED SCALE DEVELOPED AT NAVAL 
ELECTRONICS LABORATORY CENTER 

A hospital bed scale which gives a continuous display 
of a patient's weight has been developed at the Naval 
Electronics Laboratory Center in San Diego. The new 
scale is used when treatment requires constant moni- 
toring of the fluid balance of seriously injured patients, 
such as those who are severely burned or injured in a 
motor vehicle accident, sustain multiple injuries, and 
lose or gain body fluids beyond a safe limit. 

In the prototype system, two sensing units containing 
weight-sensitive strain gauge load cells are placed at 
each end of the bed. Two digital display units show the 
patient's current weight and how much he has lost or 
gained since being placed in the bed. A front panel con- 
trol ensures that data is not affected when small articles 
such as pillows and blankets are added to or removed 
from the bed. 




Prototype hospital bed scale 



NEUROLOGICAL SURGERY BOARD 
WILL GIVE EXAMINATION 

The American Board of Neurological Surgery will 
give its next oral examination 11-13 May 1977 in Cleve- 
land, Ohio. For more information write to Robert B. 
King, M.D., Secretary, American Board of Neurologi- 
cal Surgery, 750 E. Adams St., Syracuse, N.Y. 13210. 

ARMED FORCES OBSTETRICIANS AND 
GYNECOLOGISTS WILL MEET IN OCTOBER 

The 16th Annual Meeting of the Armed Forces Dis- 
trict, American College of Obstetricians and Gynecolo- 
gists, will convene at the Hyatt Regency Hotel, New 
Orleans, 9-13 Oct 1977. The Navy section of the Armed 
Forces District will sponsor this year's meeting and the 
concurrent 26th annual Armed Forces Seminar on 
Obstetrics and Gynecology. 

Postgraduate courses in gynecologic-oncologic pa- 
thology, maternal-fetal medicine and reproductive im- 
munology, and an update of obstetrics and gynecology 
for nurses will be offered during the meeting. Two 
special sessions are scheduled: a session for papers on 
current investigations in obstetrics and gynecology, 
and a panel discussion on bio-ethical debates in repro- 
ductive medicine. 

For more information, contact CAPT R.C. Cefalo, 
MC, USN, 1977 Program Chairman, AFD-ACOG, De- 
partment of Obstetrics and Gynecology, National Naval 
Medical Center, Bethesda, Md. 20014. 

NEW CARDIOTACHOMETER FROM NELC 

A new, easy-to-use digital cardiotachometer has 
been designed and a prototype built at the Navy Elec- 
tronics Laboratory Center in San Diego. When the pa- 
tient places two fingers of each hand on the two elec- 
trodes of the recording circuits, the device will compute 
the interval from one heartbeat to the next, expressing 
the heart rate in beats per minute. 

STRESS IS THEME OF NRMC OAKLAND 
NURSING CONFERENCE 

How psychiatric nurses can help patients cope with 
stress was the theme of a five-day conference for Navy 
nurses, held in November at Naval Regional Medical 
Center Oakland. Lecturers discussed patients' every- 
day strategies for coping with stress, and alternative 
coping mechanisms such as relaxation therapy and bio- 
feedback; also covered were psychosocial changes that 
increase stress, maladaptive responses — psychoso- 
matic illness, child abuse, alcoholism, depression, and 
suicide — and crisis intervention, a tool for helping pa- 
tients cope with stress. 

Speakers included members of the nursing and psy- 
chiatric staffs of the medical center, CAPT Richard 
Rahe (MC) of the Naval Health Research Center, San 
Diego, and Corrine L. Hatton, R.N., M.N., assistant 
dean of student affairs for the School of Nursing, Uni- 
versity of California at Los Angeles. 



Volume 68, March 1977 



11 



BUMEO SITREP 



THYROID DISORDERS . . . Renewed 
public interest has recently been gener- 
ated concerning the increased risk of 
thyroid disorders in individuals who re- 
ceived X- irradiation or a radium appli- 
cation to the head, neck or upper thorax 
as infants, children or young adults. 
Such procedures were accepted medical 
practice for treating various nonmalig- 
nant head and neck conditions in the 
1930-1960 era. 

Commanding officers of Navy medi- 
cal treatment facilities should coordi- 
nate with local public affairs officers in 
using available local media to alert 
members, former members or depend- 
ents who may have received such treat- 
ment of their increased risk and encour- 
age them to seek medical evaluation. 

Eligible beneficiaries may obtain 
medical evaluation at the uniformed 
services medical facility where they 
normally receive care. Former military 
members and dependents who received 
radiation therapy in a military hospital 
but who are no longer eligible for mili- 
tary health care should be encouraged 
to contact their civilian physician for 
evaluation. 

Copies of DHEW Publication No. 
(NIH) 77-1120, "Irradiation-Related 
Thyroid Cancer," have been sent to 
BUMED-commanded medical activities 
to guide physicians in the detection, 
diagnosis, treatment, and followup of 
eligible beneficiaries who request medi- 
cal evaluation for this problem. A 
limited number of extra copies of this 
publication may be obtained from the 
Office of Technical Information and Pro- 
fessional Publications, BUMED Code 
0010. 

HERE COMES THE SUN . . . Solar 
energy systems are in the works at three 
Navy medical facilities. A solar energy 
system for heating water will be in- 
stalled at the new Navy Medical and 
Dental Clinic, Naval Air Station, Cecil 
Field, Fla., and should be functioning 
this fall. Construction begins this sum- 
mer on the new naval hospital at Orlan- 
do, Fla., designed for a solar energy 
heating and hot water system; the facil- 
ity will also have solar-powered air con- 
ditioning if funding permits. Also 
designed for solar heat and hot water is 
the planned replacement medical and 
dental clinic at Naval Weapons Center, 
China Lake, Calif. 



ANTHROPOMETRIC STUDIES . . . 

BUMED and researchers at the Naval 
Aerospace Medical Research Labora- 
tory (NAMRL) in Pensacola are involved 
in the first Navywide effort to make sure 
that pilots fit their cockpits. Student 
naval aviators and student naval flight 
officers entering the Navy's aviation 
program will be measured at the Naval 
Aerospace Medical Institute (NAMI) in 
Pensacola, and their measurements re- 
duced to a four-digit code reflecting 
their sitting height, buttock-knee 
length, buttock-extended leg length, 
and functional reach. This information 
will be considered when matching crew- 
members to cockpits. The goal is to re- 
duce aircraft injuries and accidents 
which may occur when fliers are 
assigned to aircraft for which they are 
too large or too small. 

Also participating in this pilot project 
on anthropometric measurements are 
the Office of the Chief of Naval Opera- 
tions, the Bureau of Naval Personnel, 
the Naval Air Systems Command, and 
the Chief of Naval Air Training. 

NURSING CONSULTANTS . . . Nine 
Nurse Corps officers have been named 
specialty consultants to the Surgeon 
General and to the director of the Nurse 
Corps. Their first job will be to help the 
Nurse Corps review requirements for 



CAUTION 




March 20-26 

Is 

National Poison 
Prevention Week 



specific nursing billets and identify 
qualifications which meet those require- 
ments. The new consultants and their 
subspecialties are: LCDR Dorothy 
Cronin, Ob/Gyn nurse practitioner and 
nurse midwifery; LCDR Robert Downs, 
neuropsychiatric nursing; CAPT 
Katherine Howard, anesthesia; LCDR 
Jill Jarrett, neonatal intensive care 
nursing; CDR Frances Noble, maternal 
and child health nursing, and pediatric 
nurse practitioner; CDR Anne O'Con- 
nell, family nurse practitioner; LCDR 
Karen Rieder, community health 
nursing; CDR Stella A. Ross, medical, 
surgical, and critical care nursing; and 
CDR Nancy Tuttle, operating room 
nursing. 

DENTAL REGIONS ... All Navy dental 
facilities are now regionalized. In the 
final phase of regionalization, com- 
pleted last October, naval regional 
dental centers were established at Yo- 
kosuka, Japan, Camp Pendleton, Calif., 
and Orlando, Fla., bringing the total 
number of regional dental centers to 22. 
Also, in that last phase of regionaliza- 
tion, 45 branch dental clinics were 
placed under the command of regional 
dental centers. 

AUDIT TIPS . . . Activities scheduled 
for an audit should review their proce- 
dures for monitoring linen supplies. 
Linen carts and lockers must be secured 
and locked except when linen is issued 
or received. BUMED Instruction 
6770. 2B requires linen committees to 
meet at least quarterly to evaluate linen 
management and recommend any 
needed changes. Informal property 
surveys of linen supplies must be made 
and accurate records of these surveys 
kept. 

DENTAL CARTES TEST . . . Research- 
ers at the Naval Dental Research Insti- 
tute, Great Lakes, HI., have developed a 
24-hour test to determine the presence 
of decay-producing Streptococcus mu- 
tans in samples of dental plaque re- 
moved during a dental examination. 
The test helps to determine the degree 
of infection and to locate the exact sites 
on the tooth where bacteria have colo- 
nized. Details on the dental caries sus- 
ceptibility test are available from the 
Commanding Officer, Naval Dental Re- 
search Institute, Great Lakes, III. 60088. 



12 



U.S. Navy Medicine 



Scholars' Scuttlebutt 



Restructuring the GME-1 Year 



While there are many gratifying 
indications that most of our scholar- 
ship participants know and under- 
stand the initiatives the Medical 
Department is taking in graduate 
medical education, restating our 
goals and plans may clear up the 
few remaining areas of misunder- 
standing. 

The goal of the Medical Depart- 
ment's education and training pro- 
gram is the complete professional 
development of Medical Depart- 
ment members. This includes for- 
mal internships, residencies and 
fellowships. But assignments, con- 
tinuing education programs and 
refresher training are also a part of 
lifelong learning. 

One of the planned changes in 
Navy graduate medical education is 
based on the concept of learning 
through assignments: students 
completing the GME-1 year of train- 
ing will in all likelihood be assigned 
to operational billets for at least one 
year before they reenter formal 
graduate education. We think that 
interrupting training after the 
GME-1 year is far less disruptive to 
professional development than as- 
signing a fully trained specialist to 
an operational billet which does not 
require that degree of expertise. 
The fact that many young physi- 
cians change their career plans 
during the first postgraduate year 
further supports the wisdom of a 
break between the first year and 
further graduate education. Our 
new plan, which resembles the 
work-study mode of education used 
in many professions, has been ap- 
proved by the American Medical 
Association's Liaison Committee on 
Graduate Medical Education. 

We feel that the unique require- 
ments generated by the Navy mis- 
sion are not incompatible with 
sound professional development; on 
the contrary, it is just such varied 

Volume 68, March 1977 



opportunities that expand the range 
of choice for our physicians. 

Another planned change in Navy 
graduate medical education reflects 
our concern about the lack of 
enough Navy GME-1 positions to 
accommodate all graduating schol- 
arship students. Students who are 
not selected for Navy programs may 
apply for a full deferment or may be 
deferred for only one year. How- 
ever, under the rules of the scholar- 
ship program, we can grant full de- 



ferments for specialty training in 
civilian institutions only if there is 
no Navy training program available 
in that specialty, and even then only 
if the Navy has a projected need for 
the specialist's skills in the year in 
which training would be completed. 
The Navy's need for general medi- 
cal officers to support operational 
requirements is paramount and, as 
a result, opportunities are severely 
limited for full deferment. 

We recognize the difficulty facing 
students who are not selected for 
Navy GME-1 positions, since there 
are few good one-year positions in 
the civilian sector. To partially solve 
the problem, we hope to increase 
the number of Navy GME-1 training 
positions in the summer of 1978. 



USUHS 
On Tour 



The 32 members of the Uni- 
formed Services University of the 
Health Sciences charter class 
recently participated in military 
orientation activities. They vis- 
ited four Army, Navy, and Air 
Force installations, where they 
participated in military training 
exercises and were introduced to 
the medical problems they'll 
handle as military physicians. 
The charter class entered the 
USUHS School of Medicine last 
October. 

ENS John Pedrotty , above, checks out a frogman's gear at Little Creek Naval 
Amphibious Base; below, officers of the USS Charles F. Yarnell brief USUHS 
students during their visit to Norfolk. 





Clinical Notes 



A Short Guide to Bacterial and Viral 
Infections in Children 



LT Richard K. Reed, MC, USNR 



The fevers commonly encountered by primary care 
physicians who see children as outpatients are usually 
caused by viruses. Because in everyday clinical practice 
no antiviral chemotherapy is used, most fevers in chil- 
dren are managed by treating only the symptoms. This 
brief summary of viral and bacterial infections in chil- 
dren may serve as a reminder to use antibiotics judi- 
ciously. 

Invasion of the upper respiratory system by infectious 
agents is the most common cause of fever in children: 
rhinovirus, respiratory syncytial virus, adenovirus, and 
influenza virus may all enter the respiratory epithe- 
lium. Children suffering from these viruses present 
with rhinorrhea, sore throat, sneezing, malaise, and 
irritability, as well as fever; coughing, except as a reac- 
tion to postnasal drip, is not part of the syndrome since 
it originates in the lungs — the lower respiratory tract. 
On physical examination, children with upper respi- 
ratory infections may display fever, lassitude, and 
perhaps active rhinorrhea, but few other irregular find- 
ings. Routine laboratory tests are generally not needed. 
The symptoms may be treated with fluids, antipyretics, 
and if warranted, combinations of antihistamines and 
decongestants. 

Upper respiratory infections can lead to otitis media 
if the eustachian tube becomes blocked, allowing secre- 
tions to accumulate in and infect the middle ear. 
Neither redness of the tympanic membrane (hypere- 
mia) nor loss of the light reflex is a strict criterion for 
the diagnosis of otitis media. The surest sign of this 
middle ear infection is that the malleolar lateral process 
cannot be seen because the pars flaccida — Shrapnell's 
membrane — is distended. Other important signs are 
air-fluid levels and bubbles behind the tympanic mem- 
brane, and decreased movement of the eardrum when 
the patient performs the Valsalva maneuver or is 
examined with a pneumatoscope. 

Otitis media usually results from bacterial infection, 
most commonly from Diplococcus pneumoniae and — in 
approximately 20% of affected children under age 5 



LT Reed is with the Naval Regional Medical Center Long Beach 
Branch Clinic, Naval Weapons Center, China Lake, Calif. 93555. 



years — from Hemophilus influenzae. Antibiotics are 
the preferred treatment, with ampicillin in a daily 
dosage of 75-100 mg/kg of body weight recommended. 

Antihistamine-decongestant combinations may be 
used as an adjunct to therapy to decompress the 
eustachian tube. Nose drops are of dubious value. For 
children allergic to penicillin, use of erythromycin or an 
erythromycin-sulfa combination may help. In children 
over the age of 5 years, H. influenzae is a less impor- 
tant pathogen and penicillin alone may be used. But a 
child should never be given antibiotics just because he 
exhibits hyperemia and injection of the tympanic mem- 
brane, for these conditions are not reliable diagnostic 
criteria for otitis media: they can result from fever it- 
self, or from crying, allergy, viral myringitis, or 
adenoidal hypertrophy with subsequent partial block- 
age of the eustachian tube. What looks like hyperemia 
may even be the normal color of the child's eardrums, 
requiring no treatment at all. 

Although infection of the paranasal sinuses by bacte- 
ria occurs only infrequently, it almost always produces 
fever. In newborns, the maxillary sinus is rudimentary 
and very small. Then, when the child is about 3 years 
old, a rudimentary frontal sinus appears (1). Prolonged, 
purulent nasal discharge may mean that these sinuses 
are infected, and that the child has sinusitis. 

OTHER INFECTIONS 

Viruses are notorious for causing tonsillopharyngitis 
in children. The adenovirus usually causes conjunctivi- 
tis and may cause tonsillar exudation and cervical 
adenopathy. Infectious mononucleosis may cause a 
membrane to form in the pharynx, similar to the mem- 
brane caused by diphtheria. 

The main agent of bacterial tonsillopharyngitis is the 
Group A beta-hemolytic Streptococcus. Streptococcal 
sore throat is rare in children under the age of 1 year, 
and not common until after the child's second year. 
After "Strep throat" has been diagnosed by a throat 
culture on sheep blood agar plates, the treatment of 
choice is benzathine penicillin. 

Fever can also be caused by laryngotracheobronchi- 
tis, an infectious croup syndrome. Other symptoms: 



14 



U.S. Navy Medicine 



stridor, hoarseness, a brassy cough, and chest pain 
from the trachitis. This viral syndrome is treated with- 
out antibiotics; croup tents and racemic epinephrine 
inhalation are often used. Croup syndrome without 
fever should alert the physician to look for an aspirated 
foreign body, congenital vascular ring, bronchial wall 
cyst, or papillomatosis of the vocal cords. 

Acute epiglottitis, an emergency condition usually 
caused by H. influenzae, often requires tracheostomy 
because of an edematous glottis that can occlude the 
larynx. 

Coughing is produced when an infection involves the 
lower respiratory trad . The most common affliction is a 
viral bronchitis. If a cf ad shows clinical signs of toxicity 
or produces purulent sputum, a chest roentgenogram 
and blood count are indicated. Antibiotics may be used 
to treat lobar pneumonia but not viral pneumonia, usu- 
ally represented by a patchy, diffuse infiltrate. Granu- 
lomatous pulmonary disease, which may also produce 
cough, may be overlooked unless appropriate skin 
testing is performed. 

Most infections of the gastrointestinal tract are 
caused by viruses. Gastrointestinal viruses can usually 
be differentiated from bacteria by the severity of symp- 
toms (vomiting, diarrhea, and abdominal pain); the 
results of stool cultures and blood counts, and an 
examination of the stool for white cells will also help 
establish the diagnosis. While physicians disagree on 
whether to treat Shigella infections with antibiotics, 
most of them believe that antibiotics are not 
appropriate for Salmonella because a carrier state may 
be produced and resistant organisms may develop. 
Dehydration and electrolyte imbalance may result from 
excessive fluid loss fallowing vomiting and diarrhea. 
The first consideration in treating this potentially 
serious complication is to prevent this deficiency with a 
clear liquid diet for la to 24 hours. 

When no source of infection can be found in a fever- 
ish child, a urine am lysis is mandatory: urinary tract 
infection, including pyelonephritis, may be present 
without dysuria, frequent urination, or flank pain. 
Bacteria cause most urinary tract infections, while 
viruses usually infect other body systems. 

Childhood meningitis, a serious infection, may be 
caused by bacteria or viruses. Bacteria such as 
Diplococcus or Hemophilus may be implicated; 
however, in very young children, especially children 
under the age of three months, Escherichia coli and 
Salmonella may also cause meningitis (3). The patient 
with acute bacterial meningitis presents with fever, 
headaches, nausea, stiffness of the neck in flexion and 
extension movements, and positive Kernig's and 
Brudzinski's signs. However, children with a mild case 
of meningitis or in the early stage of the disease may 
present with only fever and mild headache. In the child 
under 1 year of age other signs must be sought, such as 
a bulging anterior fontanelle, excessive irritability, 
alternating periods of irritability and lethargy, and a 



high-pitched cry (2). 

To evaluate fever in a sick child who presents without 
an obvious source of infection, a white blood cell count 
and blood differential, urine analysis, and chest roent- 
genogram may be performed. If these tests reveal only 
an elevated white blood cell count in a child who looks 
ill, meningitis must be considered. A good rule of 
thumb is that fever and excessive irritability in a child 
less than 1 year old, in whom no obvious source of in- 
fection can be found, should raise the question of 
meningitis. Meningitis is diagnosed by analyzing spinal 
fluid obtained from a lumbar puncture. 

Physicians often encounter the feverish child who has 
no obvious source of infection but who does not appear 
ill enough to require a spinal tap. On the other hand, 
the physician may encounter the child who is quite ill 
but whose spinal tap produces negative results. In both 
cases, excluding the possibility of septicemia in a child 
with a toxic reaction, viral illness can usually be diag- 
nosed. The only treatment required is to prescribe 
antipyretics and continue observations. If the fever 
persists or recurs, the physician must think of such 
possibilities as juvenile rheumatoid arthritis, collagen- 
vascular diseases, rheumatic fever, malignant tumor, 
or occult abscess. 

Some physicians believe they are justified in using 
antibiotics to obviate a bacterial complication or to cure 
an inadvertently overlooked infection. But antibiotics 
should not be used to treat an infection caused by a 
virus: there is no evidence that antibiotics prevent 
secondary bacterial invasion, and they may even 
obscure a more serious infection. For example, when 
oral antibiotics are given to an outpatient with undiag- 
nosed meningitis, the subsequent spinal fluid findings 
could indicate either viral meningitis or only a partially 
treated bacterial infection. 

SUMMARY 

When a child presents with a fever, a careful history 
must be obtained and a complete physical examination 
performed. Infections of the respiratory tract are most 
common, and viruses the commonest cause of such in- 
fections. Only the symptoms should be treated. A diag- 
nosis of otitis media should be made only if the ears 
meet diagnostic criteria described above. Antibiotics 
should not be used as precautionary or prophylactic 
measures for an illness caused by a virus. 

REFERENCES 

1. Ruben RJ: The nose, paranasal sinuses, and pharynx, in 
Barnette HL (ed): Pediatrics, ed 15. New York: Appleton, Century, 
Crofts, 1972, pp 1871-1874. 

2. Hughes JG (ed): Synopsis of Pediatrics, ed 3. St. Louis: C.V. 
Mosby, 1971, pp 359-407. 

3. Weinstein L: Common sense (clinical judgment) in the diagno- 
sis and antiobiotic therapy of etiologicaily undefined infections, in 
Alvin RC (ed): Primary Care. Philadelphia: W.B. Saunders, 1974, pp 
501-518. 



Volume 68, March 1977 



15 



Professional 



Child Advocacy at Naval Regional Medical 
Center Portsmouth, Va. 

CDR Thomas Lohner, MC, USN 



The problem of child abuse and neglect is 
heightened in the military population because of 
factors common to military service, including: 

• financial burdens of junior enlisted members. 

• frequent family separations. 

• isolation from hometown friends, family and rela- 
tives, leaving parents no support in times of stress. 

• frequent moves, preventing parents from estab- 
lishing roots and learning about community re- 
sources. 

• high incidence of alcoholism. 

• limited mental health services at many naval med- 
ical facilities. 

Of paramount importance is one factor seen in 
most child abusers: they were themselves abused as 
children, and did not learn how to care for children 
properly. In child abuse cases, pediatricians often 
see an absent or passive, nonsupporting spouse, or 
parents with low self-esteem who expect too much of 
their children at various ages; also often seen are 
children who are either viewed as different or are 
indeed different because they were born premature- 
ly, have birth defects, or are hyperkinetic. Usually 
some major or minor crisis precipitates the abuse. 

In January 1975, Naval Regional Medical Center 
Portsmouth, Va. , founded a Child Advocate Com- 
mittee to deal with child abuse and vulnerable chil- 
dren in the local military community. The Commit- 
tee's purposes are: 

• to define the magnitude and scope of the child 
abuse problem among people served by the medical 
center. 

• to secure trained personnel to work with abused 
and vulnerable children. 

• to process all documented or suspected child 
abuse patients seen at the medical center— assuring 
and coordinating medical, social service, and psy- 



CDR Lohner is chairman of the Child Advocate Committee and 
a member of the Department of Pediatrics at Naval Regional 
Medical Center, Portsmouth, Va. 23708. 



chiatric care, as well as appropriate follow-up; and 
working with legal, social service, and law enforce- 
ment authorities when indicated. 

We define a vulnerable child as a child who has 
suffered from one or more of the following: physical 
abuse, neglect, emotional deprivation, failure to 
thrive, significant burns, repeated minor trauma, 
repeated drug or toxin ingestion, unexplained de- 
velopmental delay, many "accidents," physical 
injury unexplained by case history, emotionally dis- 
turbed or distraught parent, repeated clinic or emer- 
gency room visits for minor or vague complaints, an 
intellectually subnormal parent, or sexual abuse by a 
family member. 

In its first year of operation, our Committee han- 
dled 110 referrals. Of these, 75% involved physical 
abuse, while the remainder involved neglect, 
emotional abuse and deprivation, and other prob- 
lems. In the three or four years before our 
Committee was set up, only 25 such patients had 
been detected each year among our beneficiaries. 

While most referrals come from military medical 
and paramedical personnel within the region, many 
patients are referred by civilians. In a few cases, 
parent-abusers have referred themselves. We often 
sponsor lectures and discussions on child abuse to 
teach people how to identify vulnerable children and 
get help for them. 

I serve as Committee chairman.* Other members 
include the chief of pediatrics, the Committee's vice 
chairman, two staff pediatricians, a Navy chaplain, 
one representative each from the Nursing, Orthope- 
dic, Pediatric Surgery and Psychiatry Services, the 
medical center's legal officer, and a psychiatric 

*I also head the Tidewater Professional Task Force on Child 
Abuse, a team of professionals in several fields who meet regu- 
larly in an effort to improve the detection, treatment and surveil- 
lance of child abuse cases in the area (Portsmouth, Norfolk, 
Chesapeake, and Virginia Beach). This collaboration of military 
and civilian professionals enhances communication between the 
local agencies that deal with child abuse and neglect. 



16 



U.S. Navy Medicine 



social worker. A nurse from the Navy Relief Society 
and a Red Cross social worker also lend support. 
CDR Phyllis Barkus (NC), a pediatric nurse practi- 
tioner, is the Committee's coordinator. 

The Committee meets once a month to discuss pa- 
tients: diagnosis, child's condition, psychodynamics 
of the case, and possible therapies. Informal ses- 
sions are held frequently. Child advocate clinics are 
held twice a month under the direction of the 
Committee's pediatricians to evaluate and follow up 
vulnerable children and their families. 

Our management of child abuse and neglect 
resembles most other child advocacy programs: it is 
helpful, rather than punitive. Sometimes the only 
way to help is to separate the child from his family. 
In up to 15% of our patients the child's guardian has 
been so emotionally disturbed that removing the 
child from the home has been the only solution. 

Many abused children referred to the Committee 
are hospitalized immediately, not only for medical 
reasons but also to prevent further harm. A child is 
not discharged until release is medically indicated 
and family therapy has begun. A pediatrician is on 
call 24 hours a day for patient referrals. 

CASE REPORTS 

While each case of child abuse or neglect is 
unique, all are evidence of family breakdown and are 
marked by human suffering. These three brief case 
reports illustrate the range of situations our Com- 
mittee has dealt with: 

Case 1. A 23-year-old white female, mother of two girls aged 17 
months and 10 weeks, was referred to our Committee by a nurse 
practitioner. The mother was emotionally distraught and felt she 
might injure her elder daughter whom she had occasionally 
spanked "too hard." The father had left six weeks earlier on a 
six-month cruise. Reacting to the combined stress of an absent 
father and competition from the new sibling, the 17-month-old 
girl cried often, had temper tantrums and demanded constant 
attention. 

Coping with this situation became increasingly difficult for the 
mother, who never had time away from the children and had no 

Child Advocate Committee meets at NRMC Portsmouth 




family or close friends in the area. She came from a large family 
and had not been abused as a child. She had a good marriage, but 
had always been dependent on her husband. 

The mother was counseled frequently in the clinic and referred 
to the local chapter of Parents Anonymous, a self-help group for 
child abusers. She was told to call us at once if she felt she was 
losing control. After arrangements were made for a babysitter, 
the mother was able to take time for herself and was soon coping 
confidently and maturely with her children. She was seen period- 
ically in follow-up counseling until her husband returned, after 
which she had no further need for our service. 

Case 2. A 3-month-old white female was referred because she 
was eating poorly, vomiting, and not thriving. There was no ap- 
parent organic cause for these disturbances. A 3-year-old male 
sibling in the home had rubella syndrome and sensorineural deaf- 
ness. An interview with the family revealed that the parents had 
had marital difficulties the year before and had been on the verge 
of separating. But their problems were subsequently solved, and 
when we saw the child the marriage was stable. However, during 
the difficult period the father had had an affair with another 
woman who became pregnant with this child. When the child was 
born, her biological mother refused to keep her and the wife 
agreed to accept the baby because of religious convictions and 
loyalty to her husband. She found, however, that she could not 
love the child — in fact, that she hated the child, who was a 
constant reminder of her husband's previous infidelity and of her 
own imagined inadequacies as a wife. After the mother was al- 
lowed to ventilate her emotions, she came to understand that her 
feelings were natural and nothing to feel guilty about. Through 
counseling, the father gained insight into his wife's predicament. 
With the agreement of everyone concerned, the child was placed 
in foster care and subsequently adopted, and relative peace was 
restored to the family. 

Case 3. The patient was a 13-year-old white male, in the eighth 
grade, who for the previous two years had done poorly in school. 
He was accompanied to the medical center by his stepmother, 
who was apparently a stable, caring person. She had brought the 
family's problem to the attention of local social service authori- 
ties. 

The patient had a 13-year-old sister who did well in school but 
had many psychosomatic complaints, and a 9-year-old sister who 
was developmentally retarded due to emotional deprivation. The 
patient— an amiable, pleasant, communicative young man- 
related that his father was frequently abusive and violent, often 
"going berserk" with anger. The patient described his father's 
violent acts against him, his two sisters and his stepmother, and 
the father's sexual abuse of the younger sister. The stepmother 
had a child of her own from a previous marriage but this child ap- 
peared to be well protected. The stepmother, who had married 
the father eight months previously, had initiated divorce proceed- 
ings and hoped to obtain custody of all the children. For four 
years prior to the marriage the children lived with their father 
and paternal grandmother (now deceased), an extremely cruel 
person who inflicted bizarre punishments on them. Recently the 
patient had run away three times for short periods to escape his 
father's cruelty. All three children voiced a strong desire to leave 
their father, who was shown on psychiatric evaluation to be a 
borderline psychotic with a tendency to react violently. The pa- 
tient and his siblings were found to be in good physical health, 
but needed mental health care. Based on our evaluation, the 
father's parental rights were severed and the children were 
placed in foster homes. The psychiatric help they need will be 
provided. 



17 



Causes of Hospitalization 
of Active-Duty Personnel, 1974 



CDR LJ. Melton III, MC, USN 
Louis P. Hellman, Sc.D. 



One of the Navy Medical Department's most im- 
portant contributions to operational readiness is to 
neutralize risks to the health of active -duty Navy and 
Marine Corps members. The first step in minimizing 
these risks is to identify them. 

In the past, the Medical Department combated the 
obvious problems: water-borne enteric disease 
among Marines in the field, shipboard outbreaks of 
influenza, meningitis epidemics at recruit camps. 
But as medicine and military operations became 
more complex, the Navy could no longer rely on hap- 
hazard identification of major diseases, and system- 
atic epidemiological analyses have become impor- 
tant in identifying health risks in the military. 

In this paper, we report a preliminary analysis of 
the illnesses that led to hospitalization of Navy and 
Marine Corps active-duty personnel in 1974. By re- 
porting these data, we hope to provide a basis for 
discussing priorities and strategies in controlling 
serious illness and limiting noneffectiveness in the 
Navy. 

METHODS 

Most of the following data were derived from a 
provisional list of dispositions of active-duty Navy 
and Marine Corps personnel treated in Navy medical 
facilities during 1974. The figures, provided by the 
Naval Medical Data Services Center, do not include 
admissions of Navy members to other military hos- 
pitals or to civilian hospitals. Some causes of hospi- 
talization may therefore be underestimated, but the 
omissions probably do not alter the relative impor- 
tance of the disease categories. 



CDR Melton is head of the Epidemiology Section, Disease 
Analysis and Control Branch, Occupational and Preventive Medi- 
cine Division, Bureau of Medicine and Surgery, 2300 E St. N.W., 
Washington, D.C. 20372. 

Dr. Hellman is technical director of medical statistics for Naval 
Medical Data Services Center, National Naval Medical Center, 
Bethesda, Md. 20014. 



Data on hospitalization of Army and Air Force 
active-duty personnel in 1974 were provided by the 
offices of the Surgeons General of those services. 
Information about civilian hospitals is from the 
National Center for Health Statistics (2). 

RESULTS 

Specific diseases diagnosed among active-duty 
naval personnel hospitalized in 1974 were grouped 
into 18 major categories, following the International 
Classification of Diseases, Adapted (2). These 18 
categories were then ranked according to the fre- 
quency with which they appeared among Navy and 
Marine Corps members (Table I). 

The most common diagnostic group in 1974 was 
"Accidents, Poisoning and Violence," followed by 
"Mental Disorders." Together, these categories ac- 
counted for almost a third of all diagnoses reported 
by Navy medical facilities. Other categories were 
progressively less important. 

The relative importance of the categories was basi- 
cally the same in the Marine Corps as in the Navy. 
However, the actual incidence of different disease 
classes varied: in all but three classes, the Navy re- 
ported more admissions per 1,000 average strength 
than the Marines. Naval personnel also had a greater 
total hospital admissions rate than did the Marines. 
In most disease categories, the Navywide incidence 
was greater than the incidence for shipboard person- 
nel only ; however, shipboard personnel had propor- 
tionately more admissions for accidents and mental 
disorders than did Navy members altogether. 

When the individual diagnoses within each of the 
18 major categories were evaluated, the same pat- 
terns were evident. Relatively few diagnoses ac- 
counted for a substantial proportion of the admis- 
sions, and the same problems were prominent (Table 
II). Nine of the top 20 specific diagnoses leading to 
hospitalization represented trauma, and another 3 
represented mental disorders. It should be noted 
here, however, that the category "alcoholism" 



18 



U.S. Navy Medicine 



TABLE I. Relative Importance of the 18 Major Categories 

of Illness Diagnosed Among Active-Duty Navy and 

Marine Corps Personnel, 1974 



„. _ . Incidence per 1,000 


D.sease Category peop|e pef year 


Accidents, Poisoning and Violence 


31.2 


Mental Disorders 


19.2 


Diseases of the Respiratory System 


17.3 


Diseases of the Digestive System 


13.7 


Diseases of the Musculoskeletal System 


13.6 


Infective and Parasitic Diseases 


9.7 


Symptoms and Ill-defined Conditions 


9.6 


Diseases of the Skin and Subcutaneous Tissue 


9.4 


Diseases of the Genitourinary System 


8.6 


Diseases of the Circulatory System 


6.2 


Diseases of the Nervous System and Sense Organs 


5.7 


Supplementary Classifications 


4.9 


Neoplasms 


2.5 


Endocrine, Nutritional, and Metabolic Diseases 


2.4 


Congenital Anomalies 


2.1 


Complications of Pregnancy and Childbirth 


1.0 


Diseases of the Blood and Blood-forming Organs 


1.0 


Certain Perinatal Diseases 





Total 


158.1 



'According to International Classification of Diseases, Adapted 



probably does not indicate the true incidence of this 
medical problem, but rather reflects growing sup- 
port for the Navy alcoholism control program. Three 
of the 20 conditions involved surgery, and 3 more 
(not counting "cellulitis and abscess") resulted from 
infectious diseases. The remaining category was 
composed of dental problems. In listing these 20 
most prominent individual diagnoses among hos- 
pitalized personnel, we included only specific groups 
because we believed that "wastebasket" categories 
such as "all other diseases of the respiratory sys- 
tem" could not be interpreted. 

Next we ranked the 18 major disease categories in 
order of how long the victims were hospitalized 
(Table III). The two leading causes of inpatient non- 
effectiveness were "Accidents, Poisoning and Vio- 
lence" and "Mental Disorders," which together ac- 
counted for 40% of days lost through hospitalization. 
Other categories appear in much the same order as 
in Table I. Sixteen of the 20 leading specific diag- 
noses resulting in noneffectiveness (not shown) were 
among the 20 most common specific diagnoses pre- 
viously displayed in Table II. 



TABLE II. Twenty Most Common Individual Diagnoses 

Among Hospitalized Active-Duty Navy and 

Marine Corps Personnel, 1974 



Diagnosis 


Number 


Cellulitis and abscess 


3,571 


Pneumonia 


3,497 


Alcoholism 


3,336 


Acute upper respiratory tract infections 


3,133 


Inguinal hernia 


2,979 


Fracture of lower limb 


2,660 


Sprains and strains 


2,369 


Intracranial injuries (excluding'skull fracture! 


2,012 


Dental diseases and conditions 


1,786 


Fracture of upper limb 


1,692 


Internal derangement of joint 


1,686 


Transient situational disturbances 


1,675 


Dislocation without fracture 


1.665 


Contusion and crushing 


1,602 


Schizophrenia 


1,332 


Laceration of head, neck or trunk 


1,192 


Infectious hepatitis 


1,182 


Fracture of face bones 


1,137 


Acute appendicitis 


1,135 


Pilonidal cyst 


1,062 



TABLE Ml. Relative Contribution of the 18 Major Cate- 
gories of Illness to Noneffectiveness Among Active-Duty 
Navy and Marine Corps Personnel, 1974 



Disease Category* 



Noneffective 
Days 



Accidents, Poisoning and Violence 476,853 

Mental Disorders 288,424 

Diseases of Musculoskeletal System 278,901 

Diseases of the Digestive System 168,367 

Diseases of the Respiratory System 104,571 

Infective and Parasitic Diseases 102,208 

Diseases of the Circulatory System 85,847 

Diseases of Skin and Subcutaneous Tissue 78,086 

Diseases of the Nervous System and Sense Organs 72,362 

Symptoms and Ill-defined Conditions 63,042 

Diseases of the Genitourinary System 52,918 

Neoplasms 50,671 

Congenital Anomalies 34,503 

Endocrine, Nutritional, and Metabolic Diseases 26,430 

Supplementary Classifications 19,761 

Diseases of the Blood and Blood-forming Organs 7,018 

Complications of Pregnancy and Childbirth 6,148 

Certain Perinatal Diseases 



Total 



1,916,110 



'According to International Classification of Diseases, Adapted 



DISCUSSION 

These data deal only with risks that result in hospi- 
talization of active-duty personnel. Outpatient data 
might give a different picture of the relative impor- 
tance of various diseases. Also, the 1974 data reflect 
a peacetime environment: the incidence of some 



Volume 68, March 1977 



19 



categories, such as "Infective and Parasitic Diseas- 
es," might increase during mobilization or conflict. 
Keeping these reservations in mind, we can consider 
the implications of the data. 

Let us first put inpatient morbidity in perspective. 
Some 90,000 Navy and Marine Corps members were 
hospitalized in 1974 — about 12% of the active-duty 
population, assuming an average active-duty force of 
735,000 that year. Thus almost 90% of the active- 
duty force was not admitted to a medical treatment 
facility in 1974. Also, although the 90,000 hospitali- 
zations resulted in more than two million days lost 
from duty, that was only 0.7% of the total available 
man-days. Nevertheless, 90,000 admissions and two 
million days of lost productivity are still a substantial 
drain on Navy manpower. 

The data show that only a few medical problems 
accounted for most of the hospitalizations. These 
problems— accidents, respiratory and other infec- 
tions, some mental problems, and surgically correct- 
able conditions such as appendicitis and hernia— can 
be expected in any population, such as the Navy, 
where most members are less than 30 years old. 

The relative importance of the various disease 
groups was similar for each Navy community we in- 
vestigated. In other words, while the actual 
incidence of any given condition may have varied, all 
of the operational groups seemed to be experiencing 
the same major problems. 

When we compared Navy data with data on hospi- 
talization of civilians and of Army and Air Force per- 
sonnel, we found that the relative incidence of the 18 
major disease classes was similar. When categories 
involving mostly females — "Complications of Preg- 
nancy and Childbirth" and "Diseases of the Genito- 
urinary System"— were removed, the top five dis- 
ease classes among inpatients 15 to 44 years old who 
used "short-stay" civilian hospitals in 1972 were the 
same as the five most common diagnostic classes 
among Navy members. Likewise, of five disease 
classes most frequently reported by the Air Force in 
1974, four were also among the Navy's top five dis- 
ease classes; the Army shared three of the top four 
Navy disease categories in 1974. 

If the data in Table II are classified by etiology 
rather than by organ system, we find that at least 13 
of the top 20 causes of hospital admissions in 1974 
were behavioral phenomena — including accidents 
and mental disorders. Other diseases, such as infec- 
tious hepatitis and cellulitis, may have had strong 
behavioral components. Thus few of the major 
causes of Navy and Marine Corps morbidity are like- 
ly to be controlled by traditional preventive meas- 



ures directed at modifying the environment rather 
than at changing people's behavior. Many environ- 
mental intervention programs, such as immunization 
and sanitation efforts, have been successful, but pro- 
grams to change health-related behavior have been 
much less effective. Poor response to the national 
campaign against smoking is one example . 

No genuinely successful, large-scale prevention 
program, with the possible exception of our preven- 
tive dentistry program, is attacking the major causes 
of Navy and Marine Corps morbidity shown in our 
analysis. The fact that the civilian community also 
lacks effective preventive medicine programs in 
these areas is not a great consolation. Even our 
sketchy information is enough to suggest that in the 
future we must reevaluate our strategies and priori- 
ties for neutralizing risks to the health of members of 
the operating forces. More detailed analyses will 
soon provide better data on which to base our deci- 
sions, but it is not too soon to think about the prob- 
lems. 

SUMMARY 

The data in this report reflect the impact of hospi- 
talization on active-duty Navy and Marine Corps 
personnel in a peacetime environment. Almost 90 % 
of the active-duty force was not hospitalized in 1974, 
and less than 1 % of available man-days was lost to 
inpatient noneffectiveness. Most of the 90,000 hos- 
pital admissions and two million noneffective days 
that occurred in 1974 were caused by a very few con- 
ditions, predominantly accidents and mental dis- 
orders. The distribution of diseases was not surpris- 
ing for a population composed mostly of young 
males. The Navy and Marine Corps reported the 
same major diseases, and other military services and 
the civilian community had the same major disease 
problems as the Navy and Marine Corps. Many of 
the principal sources of morbidity were behavioral 
conditions which cannot be corrected by environ- 
mental manipulations. Ree valuation and innovation 
are needed to deal with these risks. 

REFERENCES 

1. Inpatient utilization of short-stay hospitals by diagnosis, 
United States, 1972. Vital and Health Statistics, series 13, no. 20. 
U.S. Department of Health, Education and Welfare, Public 
Health Service, National Center for Health Statistics. Washing- 
ton, D.C.: Nov 1975. 

2. International Classification of Diseases, Adapted. U.S. 
Department of Health, Education and Welfare, Public Health 
Service, National Center for Health Statistics, publication 1693. 
Washington, D.C.: 1968. 



20 



U.S. Navy Medicine 



Independent Duty 



Toothache Diagnosis and Treatment 

LCDR William S. Hwang, DC, USN 
LT Frank Aker, DC, USNR 



The most common dental emer- 
gency is pain — anyone who cares 
for patients in the field or in isolated 
areas has undoubtedly come across 
this problem. In this paper, we will 
identify the most common causes of 
tooth pain and discuss simple treat- 
ment procedures which independ- 
ent duty corpsmen can administer if 
a dental officer is not available. By 
using a three-part checklist — diag- 
nosis, treatment, and follow-up— 
you can relieve a patient's dental 
pain in most cases. 

CAUSES OF DENTAL PAIN 

The causes of dental pain can be 
divided into three categories: 

• Reversible pulpitis — a reversible 
inflammation of the pulp (tooth 
nerve). Reversible pulpitis can be 
caused by advancing decay when 
the pulp is still vital; the pulp can 
return to a normal condition when 
the decay is removed and the tooth 
restored. Or, a restoration that is 
large and deep can make the tooth 
hypersensitive and cause a pulpitis 
that is reversible; the hypersensitiv- 
ity of the tooth can decrease as the 
repair process takes place. 

• Irreversible pulpitis — an irrevers- 
ible disorder of the pulp which re- 
quires root canal treatment or ex- 
traction of the tooth. Any condition 



LCDR Hwang is a staff member of the De- 
partment of Endodontics, Naval Regional 
Dental Center, Great Lakes, 111. 60088. LT 
Aker is with the Dental Department, U.S. 
Naval Mobile Construction Battalion 40, FPO 
San Francisco 96601. The authors thank 
CAPT Edward M. Osetek (DC) for his guid- 
ance in preparing this article. 



which causes reversible pulpitis can 
cause irreversible pulpitis if the pa- 
tient's tooth is irritated enough. 
• Acute apical abscess — a sequel to 
untreated pulpitis, or to pulp dis- 
ease that did not respond to treat- 
ment. This condition is treated by a 
root canal procedure or by extract- 
ing the tooth. 

DIAGNOSIS 

As in any diagnosis of a health 
emergency, a history of the pa- 
tient's present complaint is of ut- 
most importance. When taking the 
patient's history, ask the patient the 
questions in Table 1. Then compare 
the patient's responses with the 
chart to determine the emergency 
condition (named at the top of the 
column). 

In most dental emergencies, the 
patient can identify the troublesome 
tooth, but in cases of reversible 
pulpitis, he may not be able to iden- 
tify the tooth that is bothering him. 
It is necessary to perform the diag- 
nostic procedures given in Table II 
and note the patient's responses. If 
there is a question concerning the 
diagnosis or which tooth is involved, 
it is best to wait and observe the 
situation until the patient presents 
with more definite symptoms. 

TREATMENT 

Once the problem has been iden- 
tified, administer treatment to alle- 
viate the patient's pain. Use only 
temporary measures until a dental 
officer can render definitive treat- 
ment. There are two temporary 



treatments: the temporary filling 
and the establishment of drainage. 
To prepare a temporary filling, 
you will need a dental mirror and 
explorer, cotton pliers, spoon exca- 
vator, plugger-type instrument, 
zinc oxide powder, and eugenol 
liquid. These instruments and ma- 
terials are essential in a dental 
emergency kit. 

To treat reversible pulpitis: 

1. Isolate the area with 2" x 2" 
gauze sponges to avoid contamina- 
tion by saliva. 

2. With a dental spoon excavator, 
remove as much debris as possible 
from the cavity. 

3. With a tongue depressor, pre- 
pare a thick mixture of zinc oxide 
and eugenol (ZnOE). 

4. Using the plugger, place the 
mixture in the dried cavity. 

5. Dispense analgesics, if neces- 
sary. 

To treat irreversible pulpitis: 

1. Remove as much debris as 
possible from the cavity. 

2. Soak a cotton pellet in eugenol, 
squeeze it dry with a gauze sponge 
and place the pellet in the cavity. 

3. Prepare a soft zinc oxide-eugenol 
(ZnOE) mixture and place the mix- 
ture over the cotton pellet in the 
cavity, using minimal pressure. 

4. Dispense analgesics, if neces- 
sary. 

To treat acute apical abscess: 

In this condition, pulpitis has 
progressed info the surrounding 
tissues. Because the abscess could 
turn into a serious, diffuse infec- 
tion, the condition requires not only 
immediate attention, but also the 
attention of a dental officer. The 
treatment is drainage of the pulp: 

1 . Record the patient' s oral temper- 
ature. 

2. Remove debris from the cavity to 
establish drainage through the 
tooth. If drainage is established, the 
patient will experience immediate 
relief. 

3. If drainage does not occur 
through the tooth and there is local- 
ized swelling of the soft tissue in the 



Volume 68, March 1977 



21 



area, establish drainage by lancing 
the soft or fluctuant swelling. 

4. Instruct the patient to use warm 
saltwater soaks (Va teaspoon salt in 
10 oz. warm water) for three min- 
utes every hour for at least one day. 

5. Dispense oral penicillin or a sub- 
stitute medication if drainage is not 
established by following steps 2 and 
3. 

6. Dispense analgesics if the pa- 
tient still has pain. 

7. Send the patient to the nearest 
dental facility. 

The final phase of emergency 
treatment is the logical extension of 
patient management: following the 
progress of the patient. As noted 
before, follow-up is imperative for 
an acute apical abscess. 

SUMMARY 

With simple diagnostic tech- 
niques and the addition of a few 
dental instruments, zinc oxide, and 
eugenol to the sick call supply kit, 
you can safely relieve most dental 
complaints, at least temporarily, 
and make the patient comfortable 
without relying on strong analge- 
sics. 



The responses below indicate: 



Reversible 
Pulpitis 



Irreversible 
Pulpitis 



TABLE I. History of Tooth Pain 



1. Have you had this pain before? 

2. Is the pain provoked by cold, 
hot, or sweet foods? 

3. Is the pain provoked by biting? 

4. Does the pain occur spontaneously, 
without being provoked? 

5. How long does the pain last? 

6. Does the pain wake you up at 
night? 

7. How much does it hurt? 



TABLE II. Diagnostic Procedure for Tooth Pain 

The answers below indicate: 



Acute Apical 
Abscess 



No 


Yes 


Yes 


Yes 


Yes 


Yes, by hot 

foods 


No 


Yes 


Yes 


No 


Yes 


Yes 


Momentary 


Prolonged 


Constant 


No 


Yes 


Yes 


Mild to 
Moderate 


Severe 


Severe 



Reversible 
Pulpitis 



1. Visual: Is the tooth decayed or 
discolored? Does it have a filling? 

2. Percussion: Determine if the tooth 
is tender by tapping it with the handle 
of a dental instrument. 

3. Thermal: Ask the patient to hold 
cold water, then warm water in his 
mouth. Notice if either causes discom- 
fort. 

4. Palpation: Feel the soft tissue 
around the tooth. Is there any soft 
swelling or abnormal enlargement in 
the area? 



Irreversible 
Pulpitis 



Acute Apical 
Abscess 



No 


Yes 


Yes 


No 


Yes 


Yes 


Yes 
(coldl 


Yes 
(warm) 


Yes 
(warm) 


No 


No 


Yes 



DON'T MISS 



Ejection Injuries: Are They Worse In Combat? 



Injuries sustained by Navy aircrewmen who ejected 
from disabled aircraft during combat in Vietnam were 
more numerous and more severe than injuries of men 
who escape from aircraft under noncombat conditions. 
In "Biomedical Aspects of Aircraft Escape and Survival 
Under Combat Conditions," the report of a study done 
for the Office of Naval Research, Martin G. Every and 
James F. Parker, Jr. discuss the stresses and adverse 
conditions fliers encounter in combat, and suggest 
ways to reduce combat pilots' chances of injury if they 
must eject. 

After studying medical data on fliers forced to eject 
during combat in Southeast Asia, the researchers con- 
cluded that most injuries involved extremity fractures 
and dislocations sustained when pilots ejected from air- 
craft flying at high speeds and relatively low altitudes. 
Serious and extensive injuries also made escape and 



rescue more difficult, as injuries were frequently com- 
pounded when the pilot attempted evasion. 

When the authors compared extent of injury for 
various ejection seats, they found that men who used 
the seat pan handle sustained more multiple flail in- 
juries than men who used the face curtain, and almost 
twice as many spinal compression fractures. Flail in- 
juries were more frequent when pilots used ejection 
seats which did not have leg restraints. Ejection 
through the canopy resulted in a disproportionate 
number of severe lacerations. 

The authors suggest that extremity restraints would 
reduce flail injuries and improve survival chances for 
Navy aircrewmen who eject at high speeds. 

The report was published in March 1976. It is avail- 
able from the authors at BioTechnoIogy, Inc., 3027 
Rosemary Lane, Falls Church, Va. 22042, 



22 



U.S. Navy Medicine 



Roster of Staff Medical and Dental Officers 
at Major Activities 



CINCPACFLT/CINCPAC (ADDU): RADM R.G.W. Williams, Jr., MC (ADDU); CAPT R.W. Bruce, DC (ADDU); 
CINCPACFLT: AO CAPT J. Wolf, MSC 

C1NCLANT/CINCLANTFLT/SACLANT (COMTRALANT): RADM P.O. Geib, MC; RADM G.A. Besbekos, DC 
(ADDU); SACLANT: AO CDR W.I. Casler, MSC 

C1NCUSNAVEUR: CAPT H.E. Shute, MC (ADDU); CAPT R.S. Nolf, DC (ADDU) 

COMNAVFOR JAPAN: CAPT G.E. Gorsuch, MC (ADDU); CAPT E.T. Witte, DC (ADDU) 

COMNAVAIRLANT: CAPT R.J. Seeley, MC; CAPT R.H. Howard, DC (ADDU) 

COMNAIRPAC: CAPT K.H. Reichardt, MC; CAPT J.E. Hyde, DC (ADDU); AO LCDR C. Schmutz, MSC 

COMSUBLANT: CDR W.B. Maffey, MC 

COMSUBPAC: CAPT R.T. Larsen, MC; CAPT R.W. Bruce, DC (ADDU) 

COMNAVSURFLANT: CAPT W.M. Phillips, MC 

COMNAVSURFPAC: CAPT J.W. Johnson, MC; AO LCDR B.L. Ozment, MSC 

FIRST NAVAL DISTRICT 

NRMCLINIC PORTSMOUTH, NH: CO CDR M.L. Cooper, MSC; XO LCDR D. McDermott, MSC; SR NUR CDR 
M. Crockett, NC 

NRMC NEWPORT, RI: CO CAPT V.L. Stotka, MC; DCS CAPT W.L. Williams, MC; DAS CDR F. Richardson, 
MSC; CH NUR CAPT L. Robinson, NC 

NRDC NEWPORT, Rl: CO CAPT L.R. Pistocco, DC; DCS CAPT C.J. Shultz, Jr., DC 

THIRD NAVAL DISTRICT 

SUB MED CEN, NEW LONDON, CT: CO CAPT J. H. Baker, MC; DCS CDR G.E. Griffin III, MC; DAS CAPT B.A. 
McKay, NC 

SUB MED RESEARCH LAB, GROTON, CT: CO CDR R.L. Spahr, Jr., MC 

FOURTH NAVAL DISTRICT 

NRMC PHILADELPHIA, PA: CO RADM R.L. Baker, MC; DCS CAPT R. A. Baker, MC; DAS CAPT H.S. Rudolph, 
MSC; CH NUR CAPT A. Foley, NC 

NRDC PHILADELPHIA: CO CAPT J.H. Scribner, DC; DCS CAPT H.E. Freeburn, Jr., DC 

NAV MED MAT SUP COM, PHILADELPHIA: CO CAPT O. Stallings, MSC; XO CDR R.E. Stockman, MSC 



Volume 68, March 1977 23 



FIFTH NAVAL DISTRICT 

NRMC PORTSMOUTH, VA: CO RADM W.J. Jacoby, Jr., MC; DCS CAPT D.C. Good, MC; DAS CDR G.W. 
Millard, MSC; CH NUR CAPT M.P. Brennan, NC 

NRDC NORFOLK, VA: CO RADM G.A. Besbekos, DC; DCS CAPT W.E. Quilter, Jr., DC; DAS CDR J.J. Kehoe, 
Jr., MSC 

NAV OPHTHALMIC SUPPORT & TRAINING ACT, WILLIAMSBURG, VA: CO CAPT M.J. Testa, MSC; XO 
CAPT J.G. Wilcox, MSC 

NAVHOS CHERRY POINT, NC: CO CAPT H.H. Coulson, MSC; DAS LCDR R. Hurder, MSC; CH NUR CDR E. 
CARSON, NC 

NRMC CAMP LEJEUNE, NC: CO CAPT T. Richter, MC; DCS CAPT C.R. Bemiller, MC; DAS CAPT W.E. 
Whitlock, MSC; CH NUR CAPT T. Proto, NC 

NRDC CAMP LEJEUNE: CO CAPT R. Slater, DC; DCS CAPT N. Luther, DC; DAS LCDR D. Wenrick, MSC 

ENVIRONMENTAL & PREV MED UNIT #2, NORFOLK, VA: OIC CAPT W.J. Brownlow, MC 

SIXTH NAVAL DISTRICT 

NRMC CHARLESTON, SC: CO CAPT E.B. McMahon, MC; DDO CAPT CH. Lowery, MC; DAS CDR G.M. Ellis, 
MSC; CH NUR CAPT R. Pampush, NC 

NRDC CHARLESTON: CO CAPT N.C. Demaree, DC; DCS CAPT W.P. Kelly, DC; DAS LCDR L.T. Foskey, MSC 

NAVHOSP BEAUFORT, SC: CO CAPT C.W. Bramlett, MC; DCS CAPT W.R. Mullins, MC; DAS CDR C.A. 
McFee, MSC; CH NUR CAPT M. Maynard, NC 

NRDC PARRIS ISLAND, SC: CO CAPT J.J. Thomas, Jr., DC; DCS CAPT A. Herr, DC 

NRMC JACKSONVILLE, FL: CO CAPT M. Museles, MC; DCS CAPT C.C. Muehe, MC; DAS CAPT H.P. Miller, 
MSC; CH NUR CAPT M.J. Walker, NC 

NRDC JACKSONVILLE: CO CAPT E. Woodland, Jr., DC; DCS CAPT E. Plump, DC; DAS LCDR M. Kern, MSC 

NAVHOSP KEY WEST, FL: CO CAPT P.F. Wells II, MC; DAS LCDR F.D.R. Fisher, MSC; CH NUR CAPT C. 
Finn, NC 

NRMC MEMPHIS, MILLINGTON, TN: CO CAPT R.M. Lehman, Jr., MC; DCS CAPT G.C. Bingham, MC; DAS 
CDR F.E. Bennett, MSC; CH NUR CAPT H.I. Furmanchik, NC 

NRMC ORLANDO, FL: CO CAPT A.L. Powell III, MC; DCS CAPT N.S. Nuredini, MC; DAS CDR L.H. Turbeville, 
MSC; CH NUR CAPT J.M. Redgate, NC 

NRDC ORLANDO: CO CAPT H.C. Pund, Jr., DC; DCS CAPT H.S. Samuels, DC; DAS CDR W.E. Grace, MSC 

NAV AEROSPACE & REG MED CEN, PENSACOLA, FL: CO RADM R.D. Nauman, MC; DCS CAPT M.C. 
Carver, MC; DAS CAPT S.D. Barker, MSC; CH NUR CAPT R. Halverson, NC 

NRDC PENSACOLA: CO CAPT J. W. Pentecost, DC; DCS CAPT S.E. Pepek, DC; DAS LCDR J.W. Smith, MSC 

NAV AEROSPACE MED RESEARCH LAB, PENSACOLA: CO CAPT R.E. Mitchel, MC 

NAV AEROSPACE MED INST, PENSACOLA: CO CAPT H.S. Trostle, MC; XO CDR T.F. Levandowski, MSC 

DISEASE VECTOR ECOLOGY & CONTROL CEN, JACKSONVILLE, FL: OIC CAPT W.B. Hull, MSC 

24 U.S. Navy Medicine 



EIGHTH NAVAL DISTRICT 

NRMC CORPUS CHRISTI, TX: CO CAPT J.R. Lukas, MC; DCS CAPT G.B. Hart, MC; DAS CDR G.W. Baldauf, 
MSC; CH NUR CAPT M. Donoghue, NC 

NRMC NEW ORLEANS, LA: CO CAPT P.C. Gregg, MC; DCS CAPT R.A. Grenier, MC; DAS CDR J.L. Graves, 
MSC; CH NUR CAPT B. Nagy, NC 

NINTH NAVAL DISTRICT 

NRMC GREAT LAKES, IL: CO CAPT M.J. Valaske, MC;DCS CAPT R.C. Elliott, MC; DAS CDR R.E. Tandy, 
MSC; CH NUR CAPT E.M. Pfeffer, NC 

NRDC GREAT LAKES: CO CAPT C.J. McLeod, DC; DCS CAPT R.D. Prince, DC; DAS CDR M.K. Law, MSC 

NAV DEN RESEARCH INST, GREAT LAKES: CO CAPT M.R. Wirthlin, DC 

NAV HOSP CORPS SCHOOL, GREAT LAKES: CO CDR V.A. Swindall, MSC; XO LCDR F. Briand, MSC; SR NUR 
CDR C. Clunan, NC 

NAV ENVIRONMENTAL HEALTH CEN, CINCINNATI, OH: OIC CAPT T.N. Markham, MC 

TENTH NAVAL DISTRICT 

NAVHOSP GUANTANAMO BAY, CUBA: CO CAPT T.J. Trumble, MC; DAS CDR W.E. Branscum, MSC; CH 
NUR CDR M. Lukacs, NC 

NAVHOSP ROOSEVELT ROADS, PR: CO CAPT W.J. Wagner, MC; DAS CDR J. Dewitt, MSC; CH NUR CAPT 

B. Slater, NC 

NRDC ROOSEVELT ROADS, PR: CO CAPT D.E. Barlow, DC; DCS CAPT R.A. Murphy, DC; DAS LCDR L.R. 
Mock, MSC 

ELEVENTH NAVAL DISTRICT 

NRMC CAMP PENDLETON, CA: CO CAPT R.F. Milnes, MC; DCS CAPT J.J. Gunning, MC; DAS CAPT F.C. 
Pittington, MSC; CH NUR CAPT P. Portz, NC 

NAV DEN CLINIC, CAMP PENDLETON: CO CAPT B.C. Sharp, DC; DCS CAPT J.D. Mahoney, DC; DAS LCDR 
J.D. Galbreath, MSC 

NRMC LONG BEACH, CA: CO CAPT E.P. Rucci, MC; DCS CAPT J. A. Zimble, MC; DAS CDR D.E. Shuler, 
MSC; CH NUR CAPT A. Williams, NC 

NRDC LONG BEACH: CO CAPT H.W. Hodson, DC; DCS CAPT F.A. Papera, DC; DAS LCDR A.E. Kennedy, 
MSC 

NAV SCHOOL HEALTH SCIENCES, SAN DIEGO, CA: CO CAPT R.E. Hunter, MSC; XO CDR G.E. Hammett, 
MSC; SR NUR CAPT M. Perlow, NC 

ENVIRONMENTAL & PREV MED UNIT #5, SAN DIEGO: OIC CAPT S.J. Kendra, MC 

NAVHOSP PORT HUENEME, CA: CO CAPT M.F. Tanner, MSC; DAS CDR J.E. Johns, MSC; CH NUR CDR M. 
Gampper, NC 

NRMC SAN DIEGO: CO RADM D.E. Brown, Jr., MC; DCS CAPT B.L. Johnson, MC; DAS CAPT E.E. Fowler, 
MSC; CH NUR CAPT D. Cornelius, NC 



Volume 68, March 1977 25 



NRDC SAN DIEGO: CO RADM W.L. Darnell, Jr., DC; DCS CAPT E.J. Heinkel, Jr., DC; DAS CDR R.W. 
Johnson, MSC 

NAV HEALTH RESEARCH CEN, SAN DIEGO: CO CAPT E.F. Coil, MC; XO CDR N.H. Berry, MSC 

TWELFTH NAVAL DISTRICT 

NRMC OAKLAND, CA: CO RADM H.A. Sparks, MC; DCS CAPT V.M. Holm, MC; DAS CDR H.H. Sowers, 
MSC; CH NUR CAPT K. Zabel, NC 

NAVHOSP LEMOORE, CA: CO CAPT E.B. Miller, MSC; DAS CDR F. Teague, MSC; CH NUR CDR J.B. Dudley, 
NC 

NAV CLINIC, SAN FRANCISCO, CA: CO CAPT W.G. Brown, MSC; XO CDR H.E. Daniel, MSC 

NRDC SAN FRANCISCO: CO CAPT J.B. Holmes, DC; DCS CAPT R.P. Morse, DC; DAS CDR G. Ramirez, MSC 

DISEASE VECTOR ECOLOGY & CONTROL CEN, ALAMEDA, CA: OIC LCDR R.V. Peterson, MSC 

NAV BIOMED RESEARCH LAB, OAKLAND: CO CDR J.F. Pribnow, MSC 



THIRTEENTH NAVAL DISTRICT 

NRMC BREMERTON, WA: CO CAPT H.P. Pariser, MC; DCS CAPT K.A. Gaines, MC; DAS CDR J.J. Palmer, 
MSC; CH NUR CAPT M.G. Stewart, NC 

NRDC BREMERTON: CO CAPT R.G. Thompson, DC; DCS CAPT J. E. Miller, DC; DAS LCDR E.C. Hansen, MSC 

NAVHOSP WHIDBEY ISLAND, OAK HARBOR, WA: CO CAPT J.C. Smout, MSC; DCS CAPT G.T. Fairfax, MC; 
DAS CDR P.O. Dilley, MSC; CH NUR CAPT L. Peterson, NC 

NAV CLINIC, NSA, SEATTLE, WA: CO CAPT C.F. Tedford, MSC; SR NUR LCDR V.E. Boyce, NC 



FOURTEENTH NAVAL DISTRICT 

NRMCLINIC PEARL HARBOR, HI: CO CAPT S.A. Youngman, MC; DAS CDR D.R. Ferguson. MSC; SR NUR 
CDR J. A. Morton, NC 

NRDC PEARL HARBOR: CO CAPT R.W. Bruce, DC; DCS CAPT T.F. McCann, DC; DAS LCDR J.D. Delaughter, 
MSC 

NAV MED ADMIN UNIT, TRIPLER ARMY HOSP, HONOLULU: OIC CDR B.L. Stephens, MSC 

ENVIRONMENTAL & PREV MED UNIT #6, PEARL HARBOR: OIC CDR T.R. Byrd, MC 

NAVAL DISTRICT, WASHINGTON, D.C. 

NAVHOSP ANNAPOLIS, MD: CO CAPT J.D. Pruitt, MSC; DCS CAPT R. A. Proulx, MC; DAS CDR A.J. Zseltvay, 
MSC; CH NUR CAPT L.E. Spencer, NC 

NATIONAL NAV MED CEN, BETHESDA, MD: CO RADM J.T. Horgan, MC; DCS CAPT Q.E. Crews, Jr., MC; 
DAS CDR G.P. Kane, MSC; CH NUR CAPT F.T. Shea, NC 

NATIONAL NAV DEN CEN, BETHESDA: CO CAPT S.T. Elder, DC; DCS CAPT A.E. Sorenson, DC; DAS CDR 
P.T. Ray, MSC 

26 U.S. Navy Medicine 



NAV HEALTH SCIENCES EDUCATION & TRAINING COMMAND, NNMC, BETHESDA: CO RADM J.W. Cox, 
MC; AO CDR D.R. Craig, MSC 

NAV SCHOOL HEALTH CARE CARE ADMIN, BETHESDA: CO CAPT E.A. Bryant, Jr., MSC; XO CDR P. 
Collier, MSC 

NAV MED RESEARCH INST, BETHESDA: CO CAPT K.W. Sell, MC; AO CDR M.L. Fitts, MSC 

NAV MED RESEARCH & DEV COM, BETHESDA: CO CAPT C.E. Brodine, MC; EXEC ASST CDR W. 
Schroeder, MSC 

ARMED FORCES INST PATHOLOGY, WASHINGTON, DC: D1R CAPT E.C. Cowart, Jr., MC 

NAV MED DATA SERV CEN, BETHESDA: CO CDR J.R. Knight, MSC; XO LCDR F.C. Anderson, MSC 

NAVHOSP PATUXENT RIVER, MD: CO CDR J.R. Erie, MSC; DAS CDR E.R. Christian, MSC; CH NUR CAPT 
D.H. Hooker, NC 

NAVHOSP QUANTICO, VA: CO CAPT R.F. Schindele, MSC; DCS CAPT I.C. Mazzarella, MC; DAS CDR R.B. 
Hinds, MSC; CH NUR CDR M.F. Hall, NC 

ITALY 

NRMC NAPLES, IT: CO CAPT H.O. Kretzschmar, MC; DCS CAPT J.V. Sharp, MC; DAS CDR J.J. Steil, MSC; 
CH NUR CAPT C. Shea, NC 

NRDC NAPLES: CO CAPT R.D. Cullom, DC; DCS CAPT J.T. Janus, DC; DAS CDR R.S. Skelly, MSC 

NAV ENVIRONMENTAL & PREV MED UNIT #7, NAPLES: OIC CAPT R.L. Marlor, MC 

JAPAN 

NRMC YOKOSUKA, JAPAN: CO CAPT G.E. Gorsuch, MC; DAS LCDR T.E. Thomas, MSC; CH NUR CDR E. 
Graves, NC 

NRDC JAPAN: CO CAPT E.T. Witte, DC; DCS CDR J.E. Matson, DC; DAS LCDR E. Piersol, MSC 

NRMC OKINAWA, JAPAN: CO CAPT C.S. Lambdin, MC; DAS CDR C. Moore, MSC; CH NUR CAPT M. Conlay, 
NC 

MARIANA ISLANDS 

NRMC GUAM, MI: CO CAPT I. J. Woodstein, MC; DCS CDR R.G. Sablan, MC; DAS CDR E.J. Hatch, MSC; CH 
NUR CDR M. Kelly, NC 

NRDC GUAM: CO CAPT P.R. Falcone, DC; DCS CAPT G.A. Short, DC; DAS LCDR L.R. Maasen, MSC 

CAIRO, EGYPT 

NAV MED RESEARCH UNIT #3, CAIRO: CO CAPT W.G. Miner, MC; AO LCDR W.A. Ferris, MSC; SR NUR 
CDR M.J. Nelson, NC 

ADDIS ABABA, ETHIOPIA 

NAV MED RESEARCH UNIT #5, ADDIS ABABA: CO CAPT R.H. Watten, MC, USNR; AO LCDR D.E. Cole, 
MSC 



Volume 68, March 1977 27 



TAIWAN 

NAVHOSP TAIPEI, TAIWAN: CO CAPT S.H. Ling, MC; DAS CDR K.L. Darr, MSC; CH NUR CDR J. Porter, NC 

NAV MED RESEARCH UNIT #2, TAIPEI: CO CDR K. Sorensen, MC 

REPUBLIC OF THE PHILIPPINES 

NAVHOSP SUBIC BAY, ROP: CO CAPT E.L. Bingham, MC; DAS CDR W.L, Blankenship, MSC; CH NUR CDR 
D.A. Yelle, NC 

NRDC SUBIC BAY: CO CAPT D.N. Firtell, DC; DCS CAPT N.H. Tracy, Jr., DC 

SPAIN 

NRMC ROTA, SPAIN: CO CAPT R.E. Kinneman, Jr., MC; DAS CDR R.A. Morin, MSC; CH NUR CDR E. 
Sullivan, NC 

HQ MARINE CORPS AND FLEET MARINE FORCE 

HQ, U.S. MARINE CORPS: CAPT D.R. Hauler, MC; CAPT A.R. Smith, DC; AO CAPT E.T. Steward, MSC 

HQ, FMF ATLANTIC: CAPT R.R. Palumbo, MC; FORDO CAPT M.C. Kohler, DC; AO LCDR R.F. Coxe, MSC 

SECOND MARINE DIVISION SURGEON: CAPT R.J. Zullo, MC; AO LCDR P.R. Milliken, MSC 

SECOND MARINE AIRCRAFT WING: CAPT E.L. Gehry, MC 

HQ, FMF PACIFIC: CAPT B.C. Johnson, MC; FORDO CAPT T.C. Enger, DC; AO CDR C.A. Roper, MSC 

FIRST MARINE DIVISION: CDR R.C. Hodges, MSC; AO LCDR A.L. Sides, MSC 

FIRST MARINE AIRCRAFT WING: CAPT P.C. Bigler, MC; AO LCDR T. Medlock, MSC 

FIRST MARINE BRIGADE: CAPT L. Fout, MC; AO LCDR G.B. Spillman, MSC 

THIRD MARINE DIVISION SURGEON: CDR CM. Day III, MC; AO LCDR G.O. McCracken, MSC 

THIRD MARINE AIRCRAFT WING: CAPT G.E. Balyeat, MC 

FIELD MED SERV SCHOOL, CAMP PENDLETON, CA: CO CAPT W.H. Jones, MSC; XO CDR E.N. Condon, 
MSC 

FIELD MED SERV SCHOOL, CAMP LEJEUNE, NC: CO CAPT L.W. Gay, MSC; XO CDR J.M. Correll, MSC 



28 U.S. Navy Medicine 



IUAVMED Newsmakers 



ENS Lilly E. Purrier (NC) won top 
honors last October at graduation 
ceremonies for the Navy's Officer 
Indoctrination School — but her hus- 
band wasn't far behind. ENS Bruce 
L. Purrier of the Civil Engineer 
Corps was runner-up in the compe- 
tition for the School's honor award. 
The Purriers are now assigned to 
Navy facilities in Port Hueneme, 
Calif. 

Patients at Naval Station Norfolk 
don't have to go to the regional den- 
tal center to find out how to save 
their teeth — preventive dentistry 
experts come to them. One who 
helps is DT3 Richard Elgin, a mem- 
ber of the dental team that passes 
out tooth-saving tips and gives fluo- 
ride treatments in a mobile van 
parked at the Navy destroyer and 
submarine piers in Norfolk. "Peo- 
ple who have been avoiding dental 
treatment often develop confidence 
in our personnel and are brought 
into a treatment program through 
contact with the mobile unit," says 
DT3 Elgin's boss, CAPT Samuel S. 
Lusk (DC). 

With only 4 doughnuts to go, DT2 
Tom Lynam had to give up his 
second attempt to crack the world 
record for eating doughnuts. "The 
last time they were day- old dough- 
nuts; this time I tried fresh ones," 
DT2 Lynam lamented. But the riper 
age of the tasty morsels didn't help: 
his stomach rebelled after number 
23, a few doughnuts short of the 27- 
doughnut record set in 1975. The 
dental technician at Branch Dental 
Clinic, New River, N.C., hopes to 
try again — maybe with chocolate 
doughnuts? 

The career of LT Sudhir D. Naik 

(MC) spans half the globe: from 
Bombay, India, where he was born 
and completed medical school, to 
his current assignment as senior 
medical officer at the Branch Clinic, 

Volume 68, March 1977 




DT3 Elgin: Have fluoride, will travel 



Navy Aviation Supply Office, Phila- 
delphia. After practicing medicine 
in Bombay for three years, Dr. Naik 
immigrated to the U.S. in 1973 and 
joined the Naval Reserve in July 
1976. While he was a resident at 
Bombay Medical College his par- 
ents arranged his marriage to Nalini 
Desai, now a third-year resident in 
psychiatry at a Philadelphia hospi- 
tal. 

The only thing better than your 
first rib-eye steak cooked over a 
campfire is your second steak — that 
was the consensus of patients and 
corpsmen at NRMC Oakland after 
the 1976 Fiddle-Footed Four- Wheel- 
ers' trek to the Sierras. Every year, 
Oakland patients and their corps- 
man-escorts are guests of the Four- 
Wheeler and San Jose Mountain 
Transit Authority Clubs for an ex- 
citing, two-day overland ride into 
the wilderness. Although this time 
out the trail was rocky and the ac- 
commodations primitive, the rough- 
riders were undaunted. The trip 
was coordinated by HMC George 
Canning; patient escorts were HM2 
Allen North, HM3 Mark Gainrich, 
and HNs Walter Adamczyk and 
William Hawkes. 



NRMC Oaklanders: Have jeep, will trek 



29 



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